Provider Demographics
NPI:1003805987
Name:IVAN, JUDITH WOLF (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:WOLF
Last Name:IVAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5998 PILGRIM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4729
Mailing Address - Country:US
Mailing Address - Phone:408-252-9086
Mailing Address - Fax:
Practice Address - Street 1:5998 PILGRIM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4729
Practice Address - Country:US
Practice Address - Phone:408-252-9086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 3233225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist