Healthcare Provider Details

I. General information

NPI: 1235461732
Provider Name (Legal Business Name): IDAHO THERAPY SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 N MIDLAND BLVD
NAMPA ID
83651-1747
US

IV. Provider business mailing address

10984 W BOX CANYON ST
STAR ID
83669-5691
US

V. Phone/Fax

Practice location:
  • Phone: 208-412-6919
  • Fax:
Mailing address:
  • Phone: 208-412-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-663
License Number StateID

VIII. Authorized Official

Name: CHRISTINE M DICKENS
Title or Position: SOLE MEMBER/OT
Credential: OT
Phone: 208-467-9117