Healthcare Provider Details

I. General information

NPI: 1831949288
Provider Name (Legal Business Name): BOUNCE BACK OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 S 2000 W
REXBURG ID
83440-4441
US

IV. Provider business mailing address

6070 S 2000 W
REXBURG ID
83440-4441
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-3340
  • Fax: 833-520-1454
Mailing address:
  • Phone: 208-356-3340
  • Fax: 833-520-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA LAGERSTROM
Title or Position: OCCUPATIONAL THERAPIST
Credential: MOTL/R
Phone: 208-356-3340