Provider Demographics
NPI:1053020198
Name:TECKLENBURG, LACI PAIGE (COTA)
Entity type:Individual
Prefix:MISS
First Name:LACI
Middle Name:PAIGE
Last Name:TECKLENBURG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4601 EAGLERIDGE PL STE 140
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-4101
Mailing Address - Country:US
Mailing Address - Phone:719-371-0443
Mailing Address - Fax:719-253-7729
Practice Address - Street 1:4601 EAGLERIDGE PL STE 140
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-4101
Practice Address - Country:US
Practice Address - Phone:719-371-0443
Practice Address - Fax:719-253-7729
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0001605224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant