Provider Demographics
NPI:1043828940
Name:NOCO PEDIATRIC OT, LLC
Entity type:Organization
Organization Name:NOCO PEDIATRIC OT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MS/OTR
Authorized Official - Phone:970-412-7361
Mailing Address - Street 1:4650 ROYAL VISTA CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80528-9321
Mailing Address - Country:US
Mailing Address - Phone:970-323-4157
Mailing Address - Fax:
Practice Address - Street 1:1931 65TH AVE STE C
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7946
Practice Address - Country:US
Practice Address - Phone:970-305-5070
Practice Address - Fax:970-541-0357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOCO PEDIATRIC OT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-16
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19205741Medicaid