Basic Information
| Provider Information | |||||||||
| NPI: | 1700036043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOARDSEN | ||||||||
| FirstName: | BRYAN | ||||||||
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| Credential: | MOT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 W TOWER PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507019026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192336995 | ||||||||
| FaxNumber: | 3192337083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056-008438 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 002042 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 002042 | 01 | IA | IOWA PT LICENSE NUMBER | OTHER |