Provider Demographics
NPI:1528381068
Name:TUMBOCON, THEDA MARIE (MAOTR/L)
Entity Type:Individual
Prefix:MS
First Name:THEDA
Middle Name:MARIE
Last Name:TUMBOCON
Suffix:
Gender:F
Credentials:MAOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16708 WINDWARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:949-636-6680
Mailing Address - Fax:
Practice Address - Street 1:16708 WINDWARD AVE
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-1659
Practice Address - Country:US
Practice Address - Phone:949-636-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist