Provider Demographics
NPI:1992236988
Name:CHASE, KATIE (COTA/L)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CHASE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:BURRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11890 W FIDDLER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3706
Practice Address - Country:US
Practice Address - Phone:208-949-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1749224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant