Healthcare Provider Details

I. General information

NPI: 1710401146
Provider Name (Legal Business Name): SPENCER CLAUSSEN COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 JACKSON ST
PUEBLO CO
81004-1830
US

IV. Provider business mailing address

314 JACKSON ST
PUEBLO CO
81004-1830
US

V. Phone/Fax

Practice location:
  • Phone: 719-369-0240
  • Fax:
Mailing address:
  • Phone: 719-369-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.0000946
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0008620
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: