Healthcare Provider Details

I. General information

NPI: 1174006886
Provider Name (Legal Business Name): ANDREA SOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2018
Last Update Date: 09/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 PROFESSIONAL CENTER PKWY
SAN RAFAEL CA
94903-2702
US

IV. Provider business mailing address

1709 KEARNY ST
PETALUMA CA
94954-3614
US

V. Phone/Fax

Practice location:
  • Phone: 415-479-5161
  • Fax:
Mailing address:
  • Phone: 415-264-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: