=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831397637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA ANN PROVINE OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 08/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N CECIL RD
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-262-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 N B ST
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-714-8460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 60224627
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT-712
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------