Provider Demographics
NPI:1558825422
Name:HOANG, NICHOLAS (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HOANG
Suffix:
Gender:M
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 1:911 BERN CT STE 140
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1242
Mailing Address - Country:US
Mailing Address - Phone:408-573-7720
Mailing Address - Fax:
Practice Address - Street 1:1401 PARKMOOR AVE STE 208
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3407
Practice Address - Country:US
Practice Address - Phone:408-885-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23325225X00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician