Provider Demographics
NPI:1477222891
Name:RICKS, KODY (COTA/L)
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:
Last Name:RICKS
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 1:152 E MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5268
Mailing Address - Country:US
Mailing Address - Phone:208-745-7101
Mailing Address - Fax:208-745-0068
Practice Address - Street 1:152 E MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5268
Practice Address - Country:US
Practice Address - Phone:208-745-7101
Practice Address - Fax:208-745-0068
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1902224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant