Healthcare Provider Details

I. General information

NPI: 1982392676
Provider Name (Legal Business Name): LITTLE ROOTS OCCUPATIONAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 04/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 CAPE MAY AVE
SAN DIEGO CA
92107-2225
US

IV. Provider business mailing address

4745 CAPE MAY AVE
SAN DIEGO CA
92107-2225
US

V. Phone/Fax

Practice location:
  • Phone: 480-244-6058
  • Fax:
Mailing address:
  • Phone: 480-244-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: CARMEN SMITH
Title or Position: OCCUPATIONAL THERAPIST, CEO
Credential: OTD
Phone: 480-244-6058