Healthcare Provider Details

I. General information

NPI: 1891092300
Provider Name (Legal Business Name): RUSTY RAKER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

618 AIRPORT RD
SUNBURY PA
17801-7007
US

V. Phone/Fax

Practice location:
  • Phone: 650-725-5106
  • Fax:
Mailing address:
  • Phone: 215-868-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 11241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: