Healthcare Provider Details

I. General information

NPI: 1134905292
Provider Name (Legal Business Name): KIDS IN BLOOM OCCUPATIONAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N HIGHWAY 33 STE 106
DRIGGS ID
83422-5313
US

IV. Provider business mailing address

3808 WOOD RD STE 106
VICTOR ID
83455-5352
US

V. Phone/Fax

Practice location:
  • Phone: 208-240-2820
  • Fax: 208-656-5647
Mailing address:
  • Phone: 208-240-2820
  • Fax: 208-656-5647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CAITLIN LYON
Title or Position: OWNER, OCCUPATIONAL THERAPIST
Credential: MOT, OTR/L
Phone: 208-240-2820