Provider Demographics
NPI:1700145752
Name:SUDHAKAR, DIXIE LYNN (OTA)
Entity Type:Individual
Prefix:MS
First Name:DIXIE
Middle Name:LYNN
Last Name:SUDHAKAR
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 BEVERLY GLEN BLVD
Mailing Address - Street 2:202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0257
Mailing Address - Country:US
Mailing Address - Phone:717-475-2642
Mailing Address - Fax:
Practice Address - Street 1:1930 S BEVERLY GLEN BLVD
Practice Address - Street 2:202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5158
Practice Address - Country:US
Practice Address - Phone:717-475-2642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA 1743224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant