Healthcare Provider Details

I. General information

NPI: 1750511085
Provider Name (Legal Business Name): SUSAN A YOUNG OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN Y REID OT

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 GRAND AVE SUITE 300
OAKLAND CA
94612-3741
US

IV. Provider business mailing address

180 GRAND AVE SUITE 300
OAKLAND CA
94612-3741
US

V. Phone/Fax

Practice location:
  • Phone: 510-835-2131
  • Fax: 510-444-2340
Mailing address:
  • Phone: 510-835-2131
  • Fax: 510-444-2340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC011111
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: