Provider Demographics
NPI:1619643590
Name:BOISE OUTDOOR OT
Entity Type:Organization
Organization Name:BOISE OUTDOOR OT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELE
Authorized Official - Middle Name:
Authorized Official - Last Name:FALLON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-918-2657
Mailing Address - Street 1:522 E 40TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-6358
Mailing Address - Country:US
Mailing Address - Phone:323-640-2305
Mailing Address - Fax:
Practice Address - Street 1:522 E 40TH ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-6358
Practice Address - Country:US
Practice Address - Phone:323-640-2305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty