Provider Demographics
NPI:1063804235
Name:MIQUELON, AGNES (OTR)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:MIQUELON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:INDIAN HILLS
Mailing Address - State:CO
Mailing Address - Zip Code:80454-0345
Mailing Address - Country:US
Mailing Address - Phone:303-697-9677
Mailing Address - Fax:
Practice Address - Street 1:22627 SHAWNEE RD.
Practice Address - Street 2:
Practice Address - City:INDIAN HILLS
Practice Address - State:CO
Practice Address - Zip Code:80454
Practice Address - Country:US
Practice Address - Phone:330-369-7967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1524225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist