Healthcare Provider Details

I. General information

NPI: 1013517606
Provider Name (Legal Business Name): COLORFUL KIDS OT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2020
Last Update Date: 11/01/2020
Certification Date: 11/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1998 ROCK SPRING RD STE D
FOREST HILL MD
21050-2664
US

IV. Provider business mailing address

1301 CHEZ CT
FALLSTON MD
21047-2206
US

V. Phone/Fax

Practice location:
  • Phone: 301-672-0159
  • Fax:
Mailing address:
  • Phone: 301-672-0159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA LEIGH DAILEY
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 301-672-0159