Provider Demographics
NPI:1033847462
Name:JOSEPH, ANTONIA MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:MARIE
Last Name:JOSEPH
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 1:3949 S NORTHBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5939
Mailing Address - Country:US
Mailing Address - Phone:208-724-8202
Mailing Address - Fax:
Practice Address - Street 1:1835 WILDWOOD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5146
Practice Address - Country:US
Practice Address - Phone:877-200-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-2158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant