Healthcare Provider Details

I. General information

NPI: 1801208079
Provider Name (Legal Business Name): CAITLIN WALL OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAITLIN ELLEDGE

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7737 MEANY AVE B5
BAKERSFIELD CA
93308-5266
US

IV. Provider business mailing address

3400 CALLOWAY DR STE 603
BAKERSFIELD CA
93312-2514
US

V. Phone/Fax

Practice location:
  • Phone: 661-377-1700
  • Fax: 661-616-9199
Mailing address:
  • Phone: 661-377-1700
  • Fax: 661-616-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT12958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: