Healthcare Provider Details

I. General information

NPI: 1851671796
Provider Name (Legal Business Name): KIM M GREGORY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 S MCCULLOCH BLVD # 20
PUEBLO WEST CO
81007-2888
US

IV. Provider business mailing address

448 S MCCULLOCH BLVD # 20
PUEBLO WEST CO
81007-2888
US

V. Phone/Fax

Practice location:
  • Phone: 719-696-1160
  • Fax:
Mailing address:
  • Phone: 719-696-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0007240
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: