Provider Demographics
NPI:1699448522
Name:RAYBURN, JOSHUA P (ORT/L)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:P
Last Name:RAYBURN
Suffix:
Gender:M
Credentials:ORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1453
Mailing Address - Country:US
Mailing Address - Phone:707-441-1931
Mailing Address - Fax:707-441-1940
Practice Address - Street 1:1587 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1453
Practice Address - Country:US
Practice Address - Phone:707-441-1931
Practice Address - Fax:707-441-1940
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22623225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist