Healthcare Provider Details

I. General information

NPI: 1093224651
Provider Name (Legal Business Name): ANNABELLE RILEY BEWICKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 ALAMEDA DE LAS PULGAS
BELMONT CA
94002-1606
US

IV. Provider business mailing address

21 SILK OAK CIR
SAN RAFAEL CA
94901-8301
US

V. Phone/Fax

Practice location:
  • Phone: 415-497-2157
  • Fax:
Mailing address:
  • Phone: 14154972157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number17287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: