Provider Demographics
NPI:1811720329
Name:VUTHEIKUN, NOAH WILLIAM (COTA/L)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:WILLIAM
Last Name:VUTHEIKUN
Suffix:
Gender:M
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 1:10434 VIA PALMA
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4751
Mailing Address - Country:US
Mailing Address - Phone:626-233-8052
Mailing Address - Fax:
Practice Address - Street 1:9620 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2320
Practice Address - Country:US
Practice Address - Phone:909-621-4751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510126224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant