=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881039451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2013
-----------------------------------------------------
Last Update Date | 05/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 GRIFFIN PL APT A
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80521-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-579-0322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 GRIFFIN PL APT A
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80521-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-579-0322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BARRY DARREN MATSUO PEDERSON
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 303-579-0322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 3123
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------