Healthcare Provider Details

I. General information

NPI: 1386337335
Provider Name (Legal Business Name): ASHLEY H RODARTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

449 S FITNESS PL
EAGLE ID
83616-6828
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax:
Mailing address:
  • Phone: 208-957-6301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTAL-2757
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: