Healthcare Provider Details

I. General information

NPI: 1730514183
Provider Name (Legal Business Name): BRAIN FIX SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAIN ST STE 657
PUEBLO CO
81003-3132
US

IV. Provider business mailing address

503 N MAIN ST STE 657
PUEBLO CO
81003-3132
US

V. Phone/Fax

Practice location:
  • Phone: 719-289-1191
  • Fax:
Mailing address:
  • Phone: 719-289-1191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number StateCO

VIII. Authorized Official

Name: BEVERLY A CARLSO
Title or Position: OWNER
Credential: IMC
Phone: 719-289-1191