Provider Demographics
NPI:1619860244
Name:BAUMGARDNER, LAURA ELLA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLA
Last Name:BAUMGARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELLA
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1180
Mailing Address - Country:US
Mailing Address - Phone:208-966-4176
Mailing Address - Fax:
Practice Address - Street 1:21651 E COUNTRY VISTA DR
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7708
Practice Address - Country:US
Practice Address - Phone:509-822-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60615300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist