Provider Demographics
NPI:1124658729
Name:GAUDI, KIMBERLY DYANNE (OTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DYANNE
Last Name:GAUDI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 47TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4516
Mailing Address - Country:US
Mailing Address - Phone:619-280-3200
Mailing Address - Fax:
Practice Address - Street 1:4421 47TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4516
Practice Address - Country:US
Practice Address - Phone:619-280-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5071OtherCA OT LICENSE
CAD2092568OtherCA DRIVER'S LICENSE