Individual
AUTUMN GROVE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8238 N GOVERNMENT WAY, HAYDEN, ID 83835-5034
(208) 762-2100
(208) 762-2101
Mailing address
8238 N GOVERNMENT WAY, HAYDEN, ID 83835-5034
(208) 762-2100
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-5390
ID
2251X0800X
Orthopedic Physical Therapist
PTL. 0013479
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PT-5390
IDAHO STATE PHYSICAL THERAPY LICENSE
ID
01
—
PTL. 0013479
COLORADO STATE PHYSICAL THERAPY LICENSE
CO
Enumeration date
05/01/2015
Last updated
08/01/2024
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