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General NPI Number Information
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NPI Number | 1518732072
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Entity Type | Individual
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Provider Name | JORDANN RYLEE GRAVES
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Gender | Female
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Dates
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Enumeration Date | 11/15/2023
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Last Update Date | 11/15/2023
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Provider Practice Location Address
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Address Line | 4630 DOOLEY WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80911-3272
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Country | US
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Telephone | 419-689-4796
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Fax |
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Provider Business Mailing Address
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Address Line | 4630 DOOLEY WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80911-3272
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Country | US
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Telephone | 419-689-4796
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OTA.0001734
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License Number State | CO
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