Provider Demographics
NPI:1245316983
Name:DEA, WILLOW (OT)
Entity type:Individual
Prefix:
First Name:WILLOW
Middle Name:
Last Name:DEA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BAYWOOD AVE
Mailing Address - Street 2:7
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1537
Mailing Address - Country:US
Mailing Address - Phone:650-344-6961
Mailing Address - Fax:650-344-6604
Practice Address - Street 1:2685 MARINE WAY
Practice Address - Street 2:SUITE 1411
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1119
Practice Address - Country:US
Practice Address - Phone:650-279-1084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTCA3473225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist