MEDICARE: FOOTPRINTS THERAPY SERVICES 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	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699418640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINTS THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	3137 EAGLE DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2815
Country	:	US
Telephone Number	:	301-646-7016
Fax Number	:

Provider Business Practice Location Address
First Line	:	3137 EAGLE DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2815
Country	:	US
Telephone Number	:	301-646-7016
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMILY FAWAZ
Credential	:	OTR/L
Telephone Number	:	301-646-7016

Provider Enumeration Date	:	04/18/2022
Last Update Date	:	04/18/2022

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