Healthcare Provider Details

I. General information

NPI: 1821615881
Provider Name (Legal Business Name): DANA ELIZABETH ZYLSTRA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W HAYCRAFT AVE STE D4
COEUR D ALENE ID
83815-8104
US

IV. Provider business mailing address

1496 W HERON AVE
HAYDEN ID
83835-8856
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2468
  • Fax: 208-667-6239
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-2218
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: