Healthcare Provider Details

I. General information

NPI: 1831410083
Provider Name (Legal Business Name): DEREK BAWDEN OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

V. Phone/Fax

Practice location:
  • Phone: 208-910-2360
  • Fax:
Mailing address:
  • Phone: 208-910-2360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT-984
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: