Healthcare Provider Details

I. General information

NPI: 1386094779
Provider Name (Legal Business Name): ARCTIC CIRCLE OCCUPATIONAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 10TH ST STE 201
CORONADO CA
92118-3420
US

IV. Provider business mailing address

1224 10TH ST STE 201
CORONADO CA
92118-3420
US

V. Phone/Fax

Practice location:
  • Phone: 619-537-6117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number11769
License Number StateCA

VIII. Authorized Official

Name: DR. TARA-RENEE WHALEN
Title or Position: CLINIC DIRECTOR
Credential: OTD, OTR/L
Phone: 619-537-6117