Provider Demographics
NPI:1437911906
Name:SMITH, GRETCHEN ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ELIZABETH
Last Name:SMITH
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 1:6028 W KIRKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-3045
Mailing Address - Country:US
Mailing Address - Phone:208-810-0620
Mailing Address - Fax:
Practice Address - Street 1:6028 W KIRKWOOD CIR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3045
Practice Address - Country:US
Practice Address - Phone:120-881-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
IDOTA-1716224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant