Healthcare Provider Details

I. General information

NPI: 1861975419
Provider Name (Legal Business Name): CARMEN RAE SMITH OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 WINDWARD WAY
CHULA VISTA CA
91914-4526
US

IV. Provider business mailing address

1415 THOMAS AVE
SAN DIEGO CA
92109-4336
US

V. Phone/Fax

Practice location:
  • Phone: 619-621-5266
  • Fax:
Mailing address:
  • Phone: 480-244-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number19183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: