Provider Demographics
NPI:1568437697
Name:SHALTRY, MARK RICHARD (OTR CHT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:SHALTRY
Suffix:
Gender:M
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:170 E STONEWATER CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-323-9747
Mailing Address - Fax:208-323-9752
Practice Address - Street 1:554 N STEELHEAD WAY
Practice Address - Street 2:STE 162
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-323-9747
Practice Address - Fax:208-323-9752
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT042225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand