Provider Demographics
NPI:1174179600
Name:DANNHARDT, KIMBERLY ANNE (COTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:DANNHARDT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3706
Mailing Address - Country:US
Mailing Address - Phone:208-949-3481
Mailing Address - Fax:208-629-1611
Practice Address - Street 1:1410 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3706
Practice Address - Country:US
Practice Address - Phone:208-949-3481
Practice Address - Fax:208-629-1611
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1449224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant