Provider Demographics
NPI:1467968636
Name:PHAM, DANIELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PHAM
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 1:4309 LOMA RIVIERA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5504
Mailing Address - Country:US
Mailing Address - Phone:714-495-0930
Mailing Address - Fax:
Practice Address - Street 1:9620 CHESAPEAKE DR STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1324
Practice Address - Country:US
Practice Address - Phone:858-859-5369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-23
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25200225X00000X
CARBT-15-02881106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician