Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 12727 | CA |
NPI | 1366925943 |
---|---|
Provider Name | Derrick Leong |
First Address | South San Francisco, CA 94080-5931 |
Second Address | South San Francisco, CA 94080-5931 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2018 |
Last Update Date | 10/09/2018 |