Provider Demographics
NPI:1063613891
Name:BOOMER, CASEY ERIK (OTRL)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ERIK
Last Name:BOOMER
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 CATALINA DR # 273
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-5928
Mailing Address - Country:US
Mailing Address - Phone:925-447-2130
Mailing Address - Fax:
Practice Address - Street 1:1440 168TH AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2409
Practice Address - Country:US
Practice Address - Phone:510-481-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8035225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist