MEDICARE: MARANDA L CENTENO 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	225X00000X	Occupational Therapist	OT.0008659	CO

General Provider Information

NPI Number	:	1356167670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARANDA L CENTENO 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	:	12/02/2024
Last Update Date	:	12/02/2024

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