Healthcare Provider Details

I. General information

NPI: 1134473846
Provider Name (Legal Business Name): ANNA LISA MATUDIO MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
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

2033 NUNES DR
SAN JOSE CA
95131-2626
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number11757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: