MEDICARE: TINY TREE OT, LLC

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1295368280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TINY TREE OT, LLC

Provider Business Mailing Address
First Line	:	2832 STONEHAVEN DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5683
Country	:	US
Telephone Number	:	970-488-0773
Fax Number	:

Provider Business Practice Location Address
First Line	:	2832 STONEHAVEN DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5683
Country	:	US
Telephone Number	:	970-488-0773
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KATHRYN SK SMITH
Credential	:	OTR/L
Telephone Number	:	970-488-0773

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	02/18/2020

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