Provider Demographics
NPI:1124663539
Name:HORTUM, RYAN (OTR/L)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:HORTUM
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 1:440 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-4890
Mailing Address - Country:US
Mailing Address - Phone:707-338-6550
Mailing Address - Fax:
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-333-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16285225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist