Provider Demographics
NPI:1639414287
Name:TAI, LEUNG S (COTA)
Entity Type:Individual
Prefix:
First Name:LEUNG
Middle Name:S
Last Name:TAI
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 TREJO ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2579
Mailing Address - Country:US
Mailing Address - Phone:208-761-0252
Mailing Address - Fax:
Practice Address - Street 1:634 TREJO ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2579
Practice Address - Country:US
Practice Address - Phone:208-761-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-09
Last Update Date:2012-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1064224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant