Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT6545 | CA |
NPI | 1003899410 |
---|---|
Provider Name | Deborah Waller |
First Address | Santa Cruz, CA 95062-1323 |
Second Address | Santa Cruz, CA 95062-2528 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2005 |
Last Update Date | 29/11/2011 |