=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992203681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. CYNTHIA KUEHNLE MACISAAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2018
-----------------------------------------------------
Last Update Date | 01/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1851 SILVER EAGLE CIR
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-9757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-406-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1851 SILVER EAGLE CIR
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-9757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-486-1689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | OT.0001785
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 0001785
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------