Individual
KENNETH WAYNE SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
12046 W SPRING RIVER CT, BOISE, ID 83709-5160
(208) 968-4302
Mailing address
12046 W SPRING RIVER CT, BOISE, ID 83709-5160
(208) 968-4302
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OTA-1091
ID
Other
Enumeration date
09/27/2011
Last updated
09/27/2011
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