Healthcare Provider Details

I. General information

NPI: 1699388520
Provider Name (Legal Business Name): MICHELLE COLQUHOUN OT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2020
Last Update Date: 08/29/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 NW HAWTHORNE AVE STE 202
BEND OR
97703-2958
US

IV. Provider business mailing address

60457 ZUNI RD
BEND OR
97702-7943
US

V. Phone/Fax

Practice location:
  • Phone: 541-408-8197
  • Fax:
Mailing address:
  • Phone: 541-408-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MICHELLE COLQUHOUN
Title or Position: OWNER
Credential: OT
Phone: 541-408-8197