Provider Demographics
NPI:1497143010
Name:CAVALLO, MARC (OTR)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:CAVALLO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 GREENWOOD HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:KNEELAND
Mailing Address - State:CA
Mailing Address - Zip Code:95549-8906
Mailing Address - Country:US
Mailing Address - Phone:707-832-9556
Mailing Address - Fax:
Practice Address - Street 1:2321 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2815
Practice Address - Country:US
Practice Address - Phone:707-725-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4304225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist