Provider Demographics
NPI:1952968604
Name:RANDOLPH, DARLA UNIQUE (COTA)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:UNIQUE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5018 MARCONI AVE APT 144
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4255
Mailing Address - Country:US
Mailing Address - Phone:916-701-7565
Mailing Address - Fax:
Practice Address - Street 1:3630 MISSION AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2933
Practice Address - Country:US
Practice Address - Phone:916-488-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3490224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant