Provider Demographics
NPI:1205867157
Name:GAUTAM, VIRENDER K (OT)
Entity Type:Individual
Prefix:
First Name:VIRENDER
Middle Name:K
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EVONVALE CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5978
Mailing Address - Country:US
Mailing Address - Phone:509-431-2795
Mailing Address - Fax:
Practice Address - Street 1:15 EVONVALE COURT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:509-431-2795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3389225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8414856Medicaid
WA0192967OtherL&I
WA8414856Medicaid
WA0192967OtherL&I