Provider Demographics
NPI:1073798476
Name:ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.
Entity Type:Organization
Organization Name:ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:WILLBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:208-892-8888
Mailing Address - Street 1:872 TROY RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4046
Mailing Address - Country:US
Mailing Address - Phone:208-892-8888
Mailing Address - Fax:208-882-8890
Practice Address - Street 1:872 TROY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4046
Practice Address - Country:US
Practice Address - Phone:208-892-8888
Practice Address - Fax:208-882-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-406174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty