Provider Demographics
NPI:1255810156
Name:WEAVER-MADDOX, TRISTIKA (COTA/L)
Entity type:Individual
Prefix:
First Name:TRISTIKA
Middle Name:
Last Name:WEAVER-MADDOX
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 CONTINENTE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-7102
Mailing Address - Country:US
Mailing Address - Phone:925-513-2440
Mailing Address - Fax:
Practice Address - Street 1:144 CONTINENTE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-7102
Practice Address - Country:US
Practice Address - Phone:925-513-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3892224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTA3892OtherOCCUPATIONAL THERAPY