Provider Demographics
NPI:1225576473
Name:QUILLEN, STACI (COTA/L)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:QUILLEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 MEINING RD
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-8514
Mailing Address - Country:US
Mailing Address - Phone:719-337-0936
Mailing Address - Fax:
Practice Address - Street 1:11968 MINERAL RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-8402
Practice Address - Country:US
Practice Address - Phone:303-652-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000577224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant