Healthcare Provider Details

I. General information

NPI: 1386557239
Provider Name (Legal Business Name): TERRELL PAYNE MOTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 ELK CREEK DR
IDAHO FALLS ID
83404-8237
US

IV. Provider business mailing address

1460 ELK CREEK DR
IDAHO FALLS ID
83404-8237
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-1286
  • Fax:
Mailing address:
  • Phone: 208-535-1286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTL-4171465
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: