Healthcare Provider Details

I. General information

NPI: 1265873004
Provider Name (Legal Business Name): PANGDEE HER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 10/08/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 W RUMBLE RD
MODESTO CA
95350-0154
US

IV. Provider business mailing address

4209 SNOWFIRE DR
MODESTO CA
95357-0898
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1001
  • Fax:
Mailing address:
  • Phone: 209-629-5289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: