Healthcare Provider Details

I. General information

NPI: 1851964787
Provider Name (Legal Business Name): SAMANTHA CHRYSTINE WALDEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 AVENIDA DEL ORO STE 118
OCEANSIDE CA
92056-5829
US

IV. Provider business mailing address

507 PINE AVE
CARLSBAD CA
92008-3014
US

V. Phone/Fax

Practice location:
  • Phone: 760-945-6500
  • Fax:
Mailing address:
  • Phone: 253-961-2759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number22541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: