Provider Demographics
NPI:1982327649
Name:POWDERLY, ELYSE MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:MARIE
Last Name:POWDERLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TARA WOODS DR APT 2
Mailing Address - Street 2:
Mailing Address - City:BUMPASS
Mailing Address - State:VA
Mailing Address - Zip Code:23024-4935
Mailing Address - Country:US
Mailing Address - Phone:732-861-2193
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2636225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist