Healthcare Provider Details

I. General information

NPI: 1659896397
Provider Name (Legal Business Name): PEGGY A ENABNIT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3498 GREEN VALLEY RD
RESCUE CA
95672-9625
US

IV. Provider business mailing address

4228 TYRONE WAY
CARMICHAEL CA
95608-1649
US

V. Phone/Fax

Practice location:
  • Phone: 530-391-8670
  • Fax: 888-538-0573
Mailing address:
  • Phone: 916-486-3664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: