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General NPI Number Information
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NPI Number | 1073798476
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Entity Type | Organization
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Legal Business Name | ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.
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Dates
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Enumeration Date | 01/03/2008
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Last Update Date | 01/03/2008
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Provider Practice Location Address
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Address Line | 872 TROY RD SUITE 170
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City | MOSCOW
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State | ID
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Zip | 83843-4046
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Country | US
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Telephone | 208-892-8888
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Fax | 208-882-8890
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Provider Business Mailing Address
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Address Line | 872 TROY RD SUITE 170
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City | MOSCOW
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State | ID
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Zip | 83843-4046
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Country | US
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Telephone | 208-892-8888
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Fax | 208-882-8890
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST OWNER
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Name | MS. DAYNA KATHLEEN WILLBANKS
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Credential | OTR/L
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Telephone | 208-892-8888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OT-406
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License Number State | ID
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