Healthcare Provider Details

I. General information

NPI: 1518413954
Provider Name (Legal Business Name): GINA TUCKER-ROGHI OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 MONTCLAIR DR
SANTA ROSA CA
95409-2821
US

IV. Provider business mailing address

717 MONTCLAIR DR
SANTA ROSA CA
95409-2821
US

V. Phone/Fax

Practice location:
  • Phone: 707-539-3328
  • Fax:
Mailing address:
  • Phone: 707-539-3328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: