Basic Information
| Provider Information | |||||||||
| NPI: | 1114189198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | AMBRUSS | ||||||||
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| Credential: | COTA/L, CLT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 392 | ||||||||
| Address2: | |||||||||
| City: | SHOSHONI | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826490392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078762284 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078569471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 626 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.