Provider Demographics
NPI:1922402544
Name:BARDEN, SIMONE ELAINE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:SIMONE
Middle Name:ELAINE
Last Name:BARDEN
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 1:2425 24TH AVE W
Mailing Address - Street 2:APT 301
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3206
Mailing Address - Country:US
Mailing Address - Phone:910-308-1588
Mailing Address - Fax:
Practice Address - Street 1:1515 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4108
Practice Address - Country:US
Practice Address - Phone:701-572-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1372224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant