Provider Demographics
NPI:1043670540
Name:UTIC, ADAM NICOLAS
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:NICOLAS
Last Name:UTIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 VILLAGE VIEW RD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5606
Mailing Address - Country:US
Mailing Address - Phone:760-505-4313
Mailing Address - Fax:
Practice Address - Street 1:7850 MISSION CENTER CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1322
Practice Address - Country:US
Practice Address - Phone:619-578-2232
Practice Address - Fax:619-578-2231
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3411224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant