=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336956176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE ROCK THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2951 US-50 ST. MARY'S BUILDING ROOM 101
-----------------------------------------------------
City | CANON CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81212-8121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-387-1137
-----------------------------------------------------
Fax | 719-434-9895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2335 FOWLER ST
-----------------------------------------------------
City | CANON CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81212-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-387-1137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MICHAEL GREENWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-387-1137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------