Provider Demographics
NPI:1730349119
Name:ELMORE, MARY LOUISE (COTA/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:ELMORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 TAHOE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1067
Mailing Address - Country:US
Mailing Address - Phone:208-841-9243
Mailing Address - Fax:
Practice Address - Street 1:2814 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5925
Practice Address - Country:US
Practice Address - Phone:208-454-0380
Practice Address - Fax:208-454-6388
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-134224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant