Provider Demographics
NPI:1215698089
Name:CAMACHO, VANESSA (OTR/L)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
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 1:2308 BROCKWAY DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4063
Mailing Address - Country:US
Mailing Address - Phone:209-543-5487
Mailing Address - Fax:
Practice Address - Street 1:2308 BROCKWAY DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4063
Practice Address - Country:US
Practice Address - Phone:209-543-5487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23012225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist