Provider Demographics
NPI:1598941643
Name:OLDHAM, ALICIA J (OT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:J
Last Name:OLDHAM
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 1:18350 MT. LANGLEY STREET
Mailing Address - Street 2:105
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-965-2324
Mailing Address - Fax:
Practice Address - Street 1:18350 MOUNT LANGLEY ST
Practice Address - Street 2:105
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6900
Practice Address - Country:US
Practice Address - Phone:714-965-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1321225X00000X
CA10448225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065477702Medicaid