Provider Demographics
NPI:1053480236
Name:BURBACK, ERIC S (OT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:BURBACK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N CURTIS RD STE 304
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1341
Mailing Address - Country:US
Mailing Address - Phone:208-342-4263
Mailing Address - Fax:208-375-0597
Practice Address - Street 1:901 N CURTIS RD STE 304
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1341
Practice Address - Country:US
Practice Address - Phone:208-342-4263
Practice Address - Fax:208-375-0597
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT461225X00000X
IDOT-461225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist