Healthcare Provider Details

I. General information

NPI: 1487994000
Provider Name (Legal Business Name): CANDICE GOLIGHTLY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 PIEDMONT AVE SUITE #3
OAKLAND CA
94611-4766
US

IV. Provider business mailing address

1037 AQUARIUS WAY
OAKLAND CA
94611-1939
US

V. Phone/Fax

Practice location:
  • Phone: 510-333-4579
  • Fax: 510-740-3491
Mailing address:
  • Phone: 510-331-8000
  • Fax: 510-740-3491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7423
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number7423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: