MEDICARE: DR. MATT MALCOLM PH.D., OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2619	CO

General Provider Information

NPI Number	:	1083985295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATT MALCOLM PH.D., OTR

Provider Business Mailing Address
First Line	:	1309 HILLSIDE DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-1974
Country	:	US
Telephone Number	:	970-420-6448
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 HILLSIDE DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-1974
Country	:	US
Telephone Number	:	970-420-6448
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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