MEDICARE: BOISE OUTDOOR OT

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	225XP0200X	Pediatric Occupational Therapist

General Provider Information

NPI Number	:	1619643590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOISE OUTDOOR OT

Provider Business Mailing Address
First Line	:	522 E 40TH ST
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-6358
Country	:	US
Telephone Number	:	323-640-2305
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 E 40TH ST
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-6358
Country	:	US
Telephone Number	:	323-640-2305
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	MRS. DANIELE FALLON
Credential	:	MA
Telephone Number	:	208-918-2657

Provider Enumeration Date	:	08/19/2021
Last Update Date	:	11/15/2021

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Directions to “BOISE OUTDOOR OT ” Practice Location

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