=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649947680
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN ROSE SYLVESTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 08/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 BELMONT DR
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80503-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-772-9292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3767 CANFIELD ST APT 108
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80301-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-623-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 0001497
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------