Provider Demographics
NPI:1649728213
Name:AUSBERGER, BRENDA (OTR)
Entity type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:
Last Name:AUSBERGER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E HOLLY ST
Mailing Address - Street 2:APT 103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7843
Mailing Address - Country:US
Mailing Address - Phone:616-706-1256
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1616225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation