Provider Demographics
NPI:1538451513
Name:OVERCAST, CLO ELLEN (RMT)
Entity type:Individual
Prefix:MS
First Name:CLO
Middle Name:ELLEN
Last Name:OVERCAST
Suffix:
Gender:F
Credentials:RMT
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 574
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-0574
Mailing Address - Country:US
Mailing Address - Phone:719-237-7958
Mailing Address - Fax:
Practice Address - Street 1:1819 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3836
Practice Address - Country:US
Practice Address - Phone:719-635-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT1169225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist