Provider Demographics
NPI:1154854297
Name:MOODY, CAMILLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11838 BERNARDO PLAZA CT
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2413
Mailing Address - Country:US
Mailing Address - Phone:858-673-5437
Mailing Address - Fax:
Practice Address - Street 1:11838 BERNARDO PLAZA CT
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2413
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16755225X00000X
OR365814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist