Provider Demographics
NPI:1477804441
Name:WISE, LINDA ELAINE (OTR)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ELAINE
Last Name:WISE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:ELAINE
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:635 PEACHTREE CT
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6353
Mailing Address - Country:US
Mailing Address - Phone:408-644-2607
Mailing Address - Fax:
Practice Address - Street 1:635 PEACHTREE CT
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6353
Practice Address - Country:US
Practice Address - Phone:408-644-2607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 4584225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist