Provider Demographics
NPI:1639670292
Name:ENOMOTO, DOROTHY (BS)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:ENOMOTO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6232
Practice Address - Country:US
Practice Address - Phone:925-754-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2023-02-04
Deactivation Date:2022-12-01
Deactivation Code:
Reactivation Date:2023-01-19
Provider Licenses
StateLicense IDTaxonomies
CA11725084106S00000X
CA106S00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician