MEDICARE: MR. BRIAN WAUTERS 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

General Provider Information

NPI Number	:	1093238925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN WAUTERS OTR

Provider Business Mailing Address
First Line	:	1218 NW VIVION RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64118-4551
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 W PROSPECT RD APT C103
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-3053
Country	:	US
Telephone Number	:	515-509-3636
Fax Number	:

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

Provider Enumeration Date	:	07/23/2017
Last Update Date	:	07/23/2017

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