Provider Demographics
NPI:1255754818
Name:CHAN, MINNIE C (OTR/L)
Entity type:Individual
Prefix:
First Name:MINNIE
Middle Name:C
Last Name:CHAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LAVAGETTO CT
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-7950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2819 CROW CANYON RD
Practice Address - Street 2:#205
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1655
Practice Address - Country:US
Practice Address - Phone:925-855-9810
Practice Address - Fax:925-263-1906
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13993225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist