Healthcare Provider Details

I. General information

NPI: 1699611855
Provider Name (Legal Business Name): INDEPENDENT EXPLORERS OCCUPATIONAL THERAPY PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 STAMPEDE DR
SPEARFISH SD
57783-9559
US

IV. Provider business mailing address

1919 STAMPEDE DR
SPEARFISH SD
57783-9559
US

V. Phone/Fax

Practice location:
  • Phone: 605-639-9367
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KELSEY BONAVIDA
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 605-639-9367