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General NPI Number Information
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NPI Number | 1750758702
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Entity Type | Individual
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Provider Name | MARESA BLACK MOT, OTR/L
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Gender | Female
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 506 ALDER ST FL 2
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City | SANDPOINT
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State | ID
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Zip | 83864-1567
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Country | US
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Telephone | 208-627-8615
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Fax | 208-441-2641
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Provider Business Mailing Address
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Address Line | PO BOX 2476
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City | SANDPOINT
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State | ID
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Zip | 83864-0914
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Country | US
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Telephone | 208-627-8615
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Fax | 208-441-2641
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | OT-1405
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License Number State | ID
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