Provider Demographics
NPI:1740563634
Name:SMITH, KENNETH WAYNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
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 1:12046 W SPRING RIVER CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5160
Mailing Address - Country:US
Mailing Address - Phone:208-968-4302
Mailing Address - Fax:
Practice Address - Street 1:12046 W SPRING RIVER CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5160
Practice Address - Country:US
Practice Address - Phone:208-968-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1091224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant