Provider Demographics
NPI:1629261318
Name:WIPF, SAM P (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:P
Last Name:WIPF
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 1:1920 MYRTLE AVE APT D
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1421
Mailing Address - Country:US
Mailing Address - Phone:707-443-2217
Mailing Address - Fax:
Practice Address - Street 1:396 DORSEY DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5368
Practice Address - Country:US
Practice Address - Phone:530-272-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-25
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT9075225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist