Provider Demographics
NPI:1679778286
Name:OCCUPATIONAL THERAPY PA
Entity type:Organization
Organization Name:OCCUPATIONAL THERAPY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:KYTLE
Authorized Official - Last Name:SEARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:MED OTR/L-ATP
Authorized Official - Phone:208-529-3358
Mailing Address - Street 1:1820 E 17TH STREET
Mailing Address - Street 2:STE. 120
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6472
Mailing Address - Country:US
Mailing Address - Phone:208-529-3358
Mailing Address - Fax:208-529-3382
Practice Address - Street 1:1820 E 17TH STREET
Practice Address - Street 2:STE. 120
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6472
Practice Address - Country:US
Practice Address - Phone:208-529-3358
Practice Address - Fax:208-529-3382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT009225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1655015Medicare ID - Type UnspecifiedINDIVIDUAL
1655273Medicare ID - Type UnspecifiedGROUP