Healthcare Provider Details

I. General information

NPI: 1538453089
Provider Name (Legal Business Name): LAURA SOPHIA LIEDTKA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 MCDONALD AVE APT B
MISSOULA MT
59801-9109
US

IV. Provider business mailing address

1207 MCDONALD AVE APT B
MISSOULA MT
59801-9109
US

V. Phone/Fax

Practice location:
  • Phone: 406-370-7176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1127
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 00003449
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number1127
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: