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General NPI Number Information
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NPI Number | 1619643590
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Entity Type | Organization
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Legal Business Name | BOISE OUTDOOR OT
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Dates
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Enumeration Date | 08/19/2021
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Last Update Date | 11/15/2021
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Provider Practice Location Address
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Address Line | 522 E 40TH ST
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City | GARDEN CITY
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State | ID
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Zip | 83714-6358
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Country | US
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Telephone | 323-640-2305
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Fax |
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Provider Business Mailing Address
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Address Line | 522 E 40TH ST
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City | GARDEN CITY
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State | ID
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Zip | 83714-6358
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Country | US
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Telephone | 323-640-2305
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MRS. DANIELE FALLON
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Credential | MA
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Telephone | 208-918-2657
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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