=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417072307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CATHLEEN M DEZOLT OTR L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12400 HIGH BLUFF DRIVE SUITE 100
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-756-0002
-----------------------------------------------------
Fax | 972-983-0290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 GRIST MILL ROAD
-----------------------------------------------------
City | WEATHERLY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC004090L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------