Provider Demographics
NPI:1073071791
Name:BOOMGARDEN, KARLIE (COTA)
Entity Type:Individual
Prefix:
First Name:KARLIE
Middle Name:
Last Name:BOOMGARDEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KARLIE
Other - Middle Name:
Other - Last Name:KINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3606
Mailing Address - Country:US
Mailing Address - Phone:307-672-2092
Mailing Address - Fax:
Practice Address - Street 1:50 W 3RD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3606
Practice Address - Country:US
Practice Address - Phone:406-728-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTA-1178224Z00000X
MTOTA-4076224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant