Provider Demographics
NPI:1538663059
Name:CONRAD, TAMMY SUE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0711
Mailing Address - Country:US
Mailing Address - Phone:208-359-9570
Mailing Address - Fax:208-359-9580
Practice Address - Street 1:36 PROFESSIONAL PLZ STE 110
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1339225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDOT-1339OtherBUREAU OF OCCUPATIONAL LICENSES