Provider Demographics
NPI:1639693013
Name:WITTMAN, KRISHNA (OTL, MPT, CEAS)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:OTL, MPT, CEAS
Other - Prefix:
Other - First Name:KRIS
Other - Middle Name:
Other - Last Name:WITTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTL, MPT, CEAS
Mailing Address - Street 1:1401 LOS GAMOS DR STE 140
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 REDWOOD HWY STE G
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5149
Practice Address - Country:US
Practice Address - Phone:415-479-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5951225X00000X
CA26347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist