=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750821914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICEA BURNAUGH MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2017
-----------------------------------------------------
Last Update Date | 06/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1597 AVENUE D SUITE 4
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-690-6996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1597 AVENUE D STE 4
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-690-6996
-----------------------------------------------------
Fax | 406-206-5262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OTP-OT-LIC-4638
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------