MEDICARE: MIA C BEVERIDGE MSOT

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	225XP0200X	Pediatric Occupational Therapist	OT.0004267	CO
2	225X00000X	Occupational Therapist	OT.0004267	CO

General Provider Information

NPI Number	:	1205100906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA C BEVERIDGE MSOT

Provider Business Mailing Address
First Line	:	PO BOX 5718
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59903-5718
Country	:	US
Telephone Number	:	406-756-0134
Fax Number	:	406-300-1612

Provider Business Practice Location Address
First Line	:	3425 AUSTIN BLUFFS PKWY STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5723
Country	:	US
Telephone Number	:	719-912-2110
Fax Number	:	719-400-6413

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

Provider Enumeration Date	:	02/28/2012
Last Update Date	:	10/06/2025

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