Provider Demographics
NPI:1285976415
Name:DICKERSON SANTANA, KYLA (OTR)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:DICKERSON SANTANA
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 1:630 S INDIAN HILL BLVD
Mailing Address - Street 2:5
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-5461
Mailing Address - Country:US
Mailing Address - Phone:909-626-8053
Mailing Address - Fax:
Practice Address - Street 1:630 S INDIAN HILL BLVD
Practice Address - Street 2:5
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5461
Practice Address - Country:US
Practice Address - Phone:909-626-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11002225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist