Healthcare Provider Details

I. General information

NPI: 1649991753
Provider Name (Legal Business Name): GERALD ANGELO CABALLERO DEOCARIZA JR. OTD, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GERALD DEOCARIZA JR. OTD, OTR/L

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W HAYCRAFT AVE STE D1
COEUR D ALENE ID
83815-8104
US

IV. Provider business mailing address

2717 N BOEING RD
SPOKANE WA
99206
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2642
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: