Provider Demographics
NPI:1477503514
Name:WITUCKI, ANGELA J (OT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:WITUCKI
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 1:1965 5TH AVE
Mailing Address - Street 2:STE 170
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2300
Mailing Address - Country:US
Mailing Address - Phone:619-851-6072
Mailing Address - Fax:619-241-2992
Practice Address - Street 1:1965 5TH AVE
Practice Address - Street 2:STE 170
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2300
Practice Address - Country:US
Practice Address - Phone:619-851-6072
Practice Address - Fax:619-241-2992
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 3375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF936ZMedicare PIN
CAWOT3375AMedicare PIN