=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437389988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLELLA C COLLIER OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2009
-----------------------------------------------------
Last Update Date | 09/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1898 FORT RD
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-8320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-672-3473
-----------------------------------------------------
Fax | 307-672-1941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1898 FORT RD
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-8320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-672-3473
-----------------------------------------------------
Fax | 307-672-1941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 0624
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OTR-812
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------