Healthcare Provider Details

I. General information

NPI: 1780204321
Provider Name (Legal Business Name): NINA CAUDILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N WINCHESTER BLVD STE 2G
SAN JOSE CA
95128-1357
US

IV. Provider business mailing address

2076 KIM LOUISE DR
CAMPBELL CA
95008-2642
US

V. Phone/Fax

Practice location:
  • Phone: 408-337-2727
  • Fax:
Mailing address:
  • Phone: 424-644-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number21168
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: