Provider Demographics
NPI:1487434288
Name:GONSAR, MARIE ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ELIZABETH
Last Name:GONSAR
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 1:9207 W STONEHAM DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-6705
Mailing Address - Country:US
Mailing Address - Phone:724-980-4298
Mailing Address - Fax:
Practice Address - Street 1:3550 W AMERICANA TER
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4728
Practice Address - Country:US
Practice Address - Phone:208-615-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist