Healthcare Provider Details

I. General information

NPI: 1679893515
Provider Name (Legal Business Name): COREY ALLEN RODERICK MA, MOT, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S FOREST ST
DENVER CO
80246-8107
US

IV. Provider business mailing address

315 S FOREST ST
DENVER CO
80246-8107
US

V. Phone/Fax

Practice location:
  • Phone: 765-585-5542
  • Fax:
Mailing address:
  • Phone: 765-585-5542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0004808
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberN/A
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: