Provider Demographics
NPI:1457511081
Name:LANDE, AUDREY MAE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:MAE
Last Name:LANDE
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 1:4430 CASA RIO DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-8559
Mailing Address - Country:US
Mailing Address - Phone:541-889-0830
Mailing Address - Fax:
Practice Address - Street 1:331 E PARK ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2053
Practice Address - Country:US
Practice Address - Phone:208-549-2416
Practice Address - Fax:208-549-0536
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-102224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant