Provider Demographics
NPI:1598189425
Name:BRADY, LAURA CHRISTINE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CHRISTINE
Last Name:BRADY
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 1:428 E 370 S
Mailing Address - Street 2:
Mailing Address - City:DIETRICH
Mailing Address - State:ID
Mailing Address - Zip Code:83324-5202
Mailing Address - Country:US
Mailing Address - Phone:208-490-4122
Mailing Address - Fax:
Practice Address - Street 1:428 E 370 S
Practice Address - Street 2:
Practice Address - City:DIETRICH
Practice Address - State:ID
Practice Address - Zip Code:83324-5202
Practice Address - Country:US
Practice Address - Phone:208-490-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist