Healthcare Provider Details

I. General information

NPI: 1013470640
Provider Name (Legal Business Name): SONOE M OFT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

527 WOODCHUCK CT
SANTA ROSA CA
95401-5751
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-5300
  • Fax:
Mailing address:
  • Phone: 707-791-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number12814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: