Provider Demographics
NPI:1295031664
Name:DEZEREGA-THOMSON, KRISTA LINA (OT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LINA
Last Name:DEZEREGA-THOMSON
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 1:4223 BOXELDER PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-6062
Mailing Address - Country:US
Mailing Address - Phone:530-400-7684
Mailing Address - Fax:
Practice Address - Street 1:96 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3084
Practice Address - Country:US
Practice Address - Phone:530-668-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT-5787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist