Provider Demographics
NPI:1699255133
Name:IMADA, CAREN SHINAYO (OTR/L)
Entity type:Individual
Prefix:
First Name:CAREN
Middle Name:SHINAYO
Last Name:IMADA
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 1:331 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2053
Mailing Address - Country:US
Mailing Address - Phone:208-549-0206
Mailing Address - Fax:
Practice Address - Street 1:331 E PARK ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2053
Practice Address - Country:US
Practice Address - Phone:208-549-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-157225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist