=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316342793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY QUACH NGUYEN OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 489 LOS COCHES ST
-----------------------------------------------------
City | MILPITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95035-5422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-941-2159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1027 EAGLE AVE
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 13915
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------