Provider Demographics
NPI:1730514183
Name:BRAIN FIX SPECIALIST, LLC
Entity type:Organization
Organization Name:BRAIN FIX SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLSO
Authorized Official - Suffix:
Authorized Official - Credentials:IMC
Authorized Official - Phone:719-289-1191
Mailing Address - Street 1:503 N MAIN ST STE 657
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3132
Mailing Address - Country:US
Mailing Address - Phone:719-289-1191
Mailing Address - Fax:
Practice Address - Street 1:503 N MAIN ST STE 657
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3132
Practice Address - Country:US
Practice Address - Phone:719-289-1191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225XN1300X, 224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental ModificationGroup - Multi-Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty