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General NPI Number Information
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NPI Number | 1235461732
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Entity Type | Organization
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Legal Business Name | IDAHO THERAPY SOURCE
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Dates
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Enumeration Date | 02/08/2010
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Last Update Date | 02/08/2010
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Provider Practice Location Address
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Address Line | 1812 N MIDLAND BLVD
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City | NAMPA
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State | ID
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Zip | 83651-1747
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Country | US
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Telephone | 208-412-6919
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Fax |
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Provider Business Mailing Address
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Address Line | 10984 W BOX CANYON ST
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City | STAR
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State | ID
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Zip | 83669-5691
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Country | US
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Telephone | 208-412-6919
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER/OT
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Name | CHRISTINE M DICKENS
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Credential | OT
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Telephone | 208-467-9117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-663
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License Number State | ID
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