=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942024997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOPE ANN FREDREGILL COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10112 W OVERLAND RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-495-5401
-----------------------------------------------------
Fax | 208-445-3939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3715 N CENTREPOINT WAY UNIT A107
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-3739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-720-1690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA-1509
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------