Provider Demographics
NPI:1649759044
Name:HOLBROOK, EDINIA SAMSON
Entity type:Individual
Prefix:
First Name:EDINIA
Middle Name:SAMSON
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4248 WEATHERVANE WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4248 WEATHERVANE WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-4213
Practice Address - Country:US
Practice Address - Phone:408-332-9946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8365225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist