Healthcare Provider Details

I. General information

NPI: 1548501257
Provider Name (Legal Business Name): GARRETT MATTHEW BREITBARTH OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11169 E I25 FRONTAGE RD
FIRESTONE CO
80504-5276
US

IV. Provider business mailing address

6615 DESERT WILLOW WAY UNIT B4
FORT COLLINS CO
80525-7805
US

V. Phone/Fax

Practice location:
  • Phone: 720-378-6670
  • Fax:
Mailing address:
  • Phone: 970-290-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT.0003632
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: