Healthcare Provider Details

I. General information

NPI: 1730453747
Provider Name (Legal Business Name): COREY SUMMERLIN ROAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5057 FRINK AVE
SAN DIEGO CA
92117-1212
US

IV. Provider business mailing address

5057 FRINK AVE
SAN DIEGO CA
92117-1212
US

V. Phone/Fax

Practice location:
  • Phone: 757-288-9512
  • Fax:
Mailing address:
  • Phone: 757-288-9512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number0119005572
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: