Provider Demographics
NPI:1306535281
Name:RUPPERT, ROBERT THOMAS (COTA/L)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:RUPPERT
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-1244
Mailing Address - Country:US
Mailing Address - Phone:949-290-9443
Mailing Address - Fax:
Practice Address - Street 1:5767 SAN FRANSICO POST ACUTE
Practice Address - Street 2:
Practice Address - City:SAN FRANSICO
Practice Address - State:CA
Practice Address - Zip Code:94112
Practice Address - Country:US
Practice Address - Phone:415-584-3294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3590224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty