Provider Demographics
NPI:1780669523
Name:SHIOTSUKA, WANDA G (OT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:G
Last Name:SHIOTSUKA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161
Mailing Address - Country:US
Mailing Address - Phone:877-325-2776
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:10565 BRUNSWICK ROAD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9053
Practice Address - Country:US
Practice Address - Phone:530-273-4152
Practice Address - Fax:530-273-4153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 5422225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01471ZMedicare ID - Type Unspecified