Provider Demographics
NPI:1861638728
Name:OSSOME, SHIVETTI B (MS, OCC THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:SHIVETTI
Middle Name:B
Last Name:OSSOME
Suffix:
Gender:F
Credentials:MS, OCC THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 TEGAN RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5149
Mailing Address - Country:US
Mailing Address - Phone:916-427-5613
Mailing Address - Fax:
Practice Address - Street 1:4813 TEGAN RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5149
Practice Address - Country:US
Practice Address - Phone:916-427-5613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-25
Last Update Date:2008-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 1173251E00000X, 261QP2000X, 261QR0401X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710918644OtherNPI