Healthcare Provider Details

I. General information

NPI: 1124634266
Provider Name (Legal Business Name): LAURA K BRUNELLO MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 E GENTRY WAY STE 180
MERIDIAN ID
83642-3014
US

IV. Provider business mailing address

2257 N ASTAIRE WAY
MERIDIAN ID
83646-3807
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3334
  • Fax:
Mailing address:
  • Phone: 208-891-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1525
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: