Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT.0006212 | CO |
NPI | 1053954982 |
---|---|
Provider Name | Jaicy Sutak |
First Address | Lyons, CO 80540-8820 |
Second Address | Denver, CO 80222-4513 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2019 |
Last Update Date | 23/10/2019 |