Healthcare Provider Details

I. General information

NPI: 1194603191
Provider Name (Legal Business Name): ROSALIA RAVELO OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

582 E HARDING WAY
STOCKTON CA
95204-6110
US

IV. Provider business mailing address

16131 5TH ST
LATHROP CA
95330-9331
US

V. Phone/Fax

Practice location:
  • Phone: 888-530-4415
  • Fax:
Mailing address:
  • Phone: 209-743-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number27934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: