Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT-757 | ID |
NPI | 1063889681 |
---|---|
Provider Name | Lisa Hartigan |
First Address | Boise, ID 83706-4025 |
Second Address | Boise, ID 83706-4025 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2015 |
Last Update Date | 31/08/2015 |