Healthcare Provider Details

I. General information

NPI: 1225373939
Provider Name (Legal Business Name): LISA D BOGGS OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MONTANA ST
GOODING ID
83330-1856
US

IV. Provider business mailing address

880 E 2700 S
HAGERMAN ID
83332-5602
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-5601
  • Fax:
Mailing address:
  • Phone: 208-358-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT335
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: