MEDICARE: MICHAEL J NORTHCUTT

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	1049	WY

General Provider Information

NPI Number	:	1780195313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J NORTHCUTT

Provider Business Mailing Address
First Line	:	3128 BOXELDER DR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-5808
Country	:	US
Telephone Number	:	307-630-7901
Fax Number	:

Provider Business Practice Location Address
First Line	:	2163 CHANDLER ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-7085
Country	:	US
Telephone Number	:	970-282-9181
Fax Number	:

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

Provider Enumeration Date	:	10/23/2017
Last Update Date	:	10/23/2017

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