Provider Demographics
NPI:1225620602
Name:OUTLANDER OCCUPATIONAL THEARPY, LLC
Entity Type:Organization
Organization Name:OUTLANDER OCCUPATIONAL THEARPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:240-310-8468
Mailing Address - Street 1:3201 KAGE RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 KAGE RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2107
Practice Address - Country:US
Practice Address - Phone:240-310-8468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty