Basic Information
| Provider Information | |||||||||
| NPI: | 1841756947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACKER | ||||||||
| FirstName: | BRIANA | ||||||||
| MiddleName: | NORA TYNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100 | ||||||||
| Address2: | |||||||||
| City: | KETCHUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833400100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087278800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | KETCHUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087278100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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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 | 225X00000X | OT-2032 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT-2032 | 01 | ID | IDAHO OCCUPATIONAL THERAPY LICENSE | OTHER |