Healthcare Provider Details

I. General information

NPI: 1114081569
Provider Name (Legal Business Name): LESLEY RUBY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 ADDISON AVE
TWIN FALLS ID
83301-5203
US

IV. Provider business mailing address

840 ADDISON AVE
TWIN FALLS ID
83301-5203
US

V. Phone/Fax

Practice location:
  • Phone: 208-595-4941
  • Fax: 208-595-4931
Mailing address:
  • Phone: 208-595-4941
  • Fax: 208-595-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberOT-242
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberOT-242
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-242
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: