Provider Demographics
NPI:1205609344
Name:DIZON, CARMELA GRACE (MS OTR/L)
Entity type:Individual
Prefix:
First Name:CARMELA
Middle Name:GRACE
Last Name:DIZON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 ANTOINETTE LN APT D
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3375
Mailing Address - Country:US
Mailing Address - Phone:650-504-2413
Mailing Address - Fax:
Practice Address - Street 1:822 ANTOINETTE LN APT D
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3375
Practice Address - Country:US
Practice Address - Phone:650-504-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24521225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist