Healthcare Provider Details

I. General information

NPI: 1881891760
Provider Name (Legal Business Name): LAURA JEAN GODEREZ MS, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

747 52ND ST
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-8412
  • Fax: 510-238-9764
Mailing address:
  • Phone: 510-428-8412
  • Fax: 510-238-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: