Provider Demographics
NPI:1184166316
Name:BLANTON-HUBBARD, ELISE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:BLANTON-HUBBARD
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 JOSEPHINE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1108
Mailing Address - Country:US
Mailing Address - Phone:831-277-8368
Mailing Address - Fax:
Practice Address - Street 1:391 TAYLOR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2289
Practice Address - Country:US
Practice Address - Phone:925-608-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X
IDOT-1656225X00000X
CAOT16845225X00000X, 225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist