Provider Demographics
NPI:1336150515
Name:FENTON, ZENE FAWN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ZENE
Middle Name:FAWN
Last Name:FENTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:ZENE
Other - Middle Name:FAWN
Other - Last Name:GERVAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2360 MENDOCINO AVE
Mailing Address - Street 2:A2 #173
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3153
Mailing Address - Country:US
Mailing Address - Phone:707-544-2637
Mailing Address - Fax:707-544-2088
Practice Address - Street 1:2305 MENDOCINO AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3157
Practice Address - Country:US
Practice Address - Phone:707-544-2637
Practice Address - Fax:707-544-2088
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2583225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT-0025830OtherBLUE SHIELD
CAZZZ04556ZMedicare PIN