Individual
MR. KRISTOPHER DWAYNE WALLIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
8211 W USTICK RD, BOISE, ID 83704-5756
(208) 375-3700
Mailing address
979 E ENSOLORADO ST, KUNA, ID 83634-5179
(208) 608-0809
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OTA-1423
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
340040
NATIONAL BOARD OF OCCUPATIONAL THERAPY
—
Enumeration date
05/24/2015
Last updated
05/24/2015
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