Provider Demographics
NPI:1003642414
Name:FADER, TODD (OT)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:FADER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 112
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7243
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:760-771-9057
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist