Healthcare Provider Details

I. General information

NPI: 1255158028
Provider Name (Legal Business Name): ELIJAH KAI WILLIAMS OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4418
US

IV. Provider business mailing address

4845 BRIDGEWATER CIR
STOCKTON CA
95219-2010
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 209-262-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number26100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: