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
StateLicense IDTaxonomies
CAOT5244225X00000X, 225XF0002X, 225XN1300X, 225XP0019X, 225XP0200X
CAOT 681225X00000X, 225XE1200X, 225XG0600X, 225XH1200X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ033712OtherMEDICARE ID, UNSPECIFIED
CAQ59049Medicare UPIN
CAZZZ033712OtherMEDICARE ID, UNSPECIFIED