Provider Demographics
NPI:1710505565
Name:QUACH, JOHNATHAN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:QUACH
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 BOBBY LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-1249
Mailing Address - Country:US
Mailing Address - Phone:714-343-4834
Mailing Address - Fax:
Practice Address - Street 1:14221 EUCLID ST STE F
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4991
Practice Address - Country:US
Practice Address - Phone:714-891-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21284225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist