Healthcare Provider Details

I. General information

NPI: 1619860244
Provider Name (Legal Business Name): LAURA ELLA BAUMGARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ELLA BURCH

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21651 E COUNTRY VISTA DR
LIBERTY LAKE WA
99019-7708
US

IV. Provider business mailing address

PO BOX 1180
HAYDEN ID
83835-1180
US

V. Phone/Fax

Practice location:
  • Phone: 509-822-7834
  • Fax:
Mailing address:
  • Phone: 208-966-4176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60615300
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: