Healthcare Provider Details

I. General information

NPI: 1639693013
Provider Name (Legal Business Name): KRISHNA WITTMAN OTL, MPT, CEAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRIS WITTMAN OTL, MPT, CEAS

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 REDWOOD HWY STE G
SAN RAFAEL CA
94903-5149
US

IV. Provider business mailing address

1401 LOS GAMOS DR STE 140
SAN RAFAEL CA
94903-1832
US

V. Phone/Fax

Practice location:
  • Phone: 415-479-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number26347
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: