Healthcare Provider Details

I. General information

NPI: 1174381990
Provider Name (Legal Business Name): DUSTIN SKYLAR DOUROS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOOVER LN
NEVADA CITY CA
95959-2944
US

IV. Provider business mailing address

1005 LEWIS CIR
SANTA CRUZ CA
95062-4350
US

V. Phone/Fax

Practice location:
  • Phone: 530-265-0618
  • Fax:
Mailing address:
  • Phone: 530-575-8818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: