Provider Demographics
NPI:1376836155
Name:PATEL-VENKETSAMY, NISHA KANTIDEV (OT)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:KANTIDEV
Last Name:PATEL-VENKETSAMY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:NISHA
Other - Middle Name:KANTIDEV
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4626 WILLOW RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8517
Mailing Address - Country:US
Mailing Address - Phone:925-463-0470
Mailing Address - Fax:925-463-0473
Practice Address - Street 1:4626 WILLOW RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8517
Practice Address - Country:US
Practice Address - Phone:925-463-0470
Practice Address - Fax:925-463-0473
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2828225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT2828OtherMEDICAL LICENSE
CAP01003597OtherMEDICARE RAILROAD
CAFD839YMedicare PIN
CAP01003597OtherMEDICARE RAILROAD
CAOT2828OtherMEDICAL LICENSE