Provider Demographics
NPI: | 1649574807 |
---|---|
Name: | GOLD COUNTRY OCCUPATIONAL THERAPY |
Entity Type: | Organization |
Organization Name: | GOLD COUNTRY OCCUPATIONAL THERAPY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OCCUPATIONAL THERAPIST |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | SUSAN |
Authorized Official - Middle Name: | MARY |
Authorized Official - Last Name: | LYNEIS-SIRIAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OTR |
Authorized Official - Phone: | 209-736-9589 |
Mailing Address - Street 1: | PO BOX 278 |
Mailing Address - Street 2: | |
Mailing Address - City: | ANGELS CAMP |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95222-0278 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 209-743-7211 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 252 N. MAIN STREET |
Practice Address - Street 2: | |
Practice Address - City: | ANGELS CAMP |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95222 |
Practice Address - Country: | US |
Practice Address - Phone: | 209-736-9589 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-01-03 |
Last Update Date: | 2011-01-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | OT5244 | 225X00000X, 225XF0002X, 225XN1300X, 225XP0019X, 225XP0200X |
CA | OT 681 | 225X00000X, 225XE1200X, 225XG0600X, 225XH1200X, 225XP0019X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 225XE1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics | Group - Multi-Specialty |
No | 225XF0002X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Feeding, Eating & Swallowing | Group - Multi-Specialty |
No | 225XG0600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology | Group - Multi-Specialty |
No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
No | 225XN1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Neurorehabilitation | Group - Multi-Specialty |
No | 225XP0019X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | Group - Multi-Specialty |
No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | ZZZ033712 | Other | MEDICARE ID, UNSPECIFIED |
CA | Q59049 | Medicare UPIN | |
CA | ZZZ033712 | Other | MEDICARE ID, UNSPECIFIED |