Provider Demographics
NPI:1811386139
Name:GHAISAS, SAMRUDDHI (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMRUDDHI
Middle Name:
Last Name:GHAISAS
Suffix:
Gender:F
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 1:638 S MARENGO AVE
Mailing Address - Street 2:APT. 8
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3838
Practice Address - Country:US
Practice Address - Phone:626-282-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 12851225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist