MEDICARE: MRS. COURTNEY WILEY OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT-2596	ID

General Provider Information

NPI Number	:	1316679038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COURTNEY WILEY OTR/L

Provider Business Mailing Address
First Line	:	474 S 100 W
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-6089
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 E AVENUE F
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-3132
Country	:	US
Telephone Number	:	208-324-2443
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	06/30/2022

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