Provider Demographics
NPI:1376213850
Name:RUPE, BROOKE SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:SUE
Last Name:RUPE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 REBEL RD
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-419-8894
Mailing Address - Fax:
Practice Address - Street 1:1460 ELK CREEK DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8237
Practice Address - Country:US
Practice Address - Phone:208-535-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-2264224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDOTA-2264OtherSTATE ISSUED LICENSE