Provider Demographics
NPI:1063111813
Name:SEVILLA, EDWARD JOSEPH (OTR/L)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:SEVILLA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 BEACHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-3608
Mailing Address - Country:US
Mailing Address - Phone:209-761-9890
Mailing Address - Fax:
Practice Address - Street 1:1610 ARDEN WAY STE 195
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4035
Practice Address - Country:US
Practice Address - Phone:137-991-6649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist