Provider Demographics
NPI:1629392246
Name:VINNICOMBE, BRENDA JOHANSON (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JOHANSON
Last Name:VINNICOMBE
Suffix:
Gender:F
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 1:2014 CHURTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6905
Mailing Address - Country:US
Mailing Address - Phone:650-967-7190
Mailing Address - Fax:650-967-7841
Practice Address - Street 1:2014 CHURTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-6905
Practice Address - Country:US
Practice Address - Phone:650-967-7190
Practice Address - Fax:650-967-7841
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT10816225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist