Provider Demographics
NPI:1609518166
Name:PALOUSE RIDGE OCCUPATIONAL THERAPY PLLC
Entity type:Organization
Organization Name:PALOUSE RIDGE OCCUPATIONAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-669-3186
Mailing Address - Street 1:1026 GRANGE PARK RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:ID
Mailing Address - Zip Code:83857-5500
Mailing Address - Country:US
Mailing Address - Phone:208-669-3186
Mailing Address - Fax:
Practice Address - Street 1:510 ELM ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-669-3186
Practice Address - Fax:208-747-0782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty