Provider Demographics
NPI:1538453089
Name:LIEDTKA, LAURA SOPHIA (OTR/L)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SOPHIA
Last Name:LIEDTKA
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 1:1207 MCDONALD AVE APT B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-9109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1207 MCDONALD AVE APT B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-9109
Practice Address - Country:US
Practice Address - Phone:406-370-7176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1127225XF0002X, 225XP0200X
WAOT 00003449225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing