Provider Demographics
NPI:1033654900
Name:EARL, TYLER (COTA/L)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:EARL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2106
Mailing Address - Country:US
Mailing Address - Phone:208-677-3073
Mailing Address - Fax:
Practice Address - Street 1:2303 PARK AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2106
Practice Address - Country:US
Practice Address - Phone:208-677-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1278224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant