Provider Demographics
NPI:1972079457
Name:PARIDA, MANOJ K (OTR/L)
Entity type:Individual
Prefix:
First Name:MANOJ
Middle Name:K
Last Name:PARIDA
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 1:350 NUGGET CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2312
Mailing Address - Country:US
Mailing Address - Phone:818-314-5774
Mailing Address - Fax:818-484-2146
Practice Address - Street 1:350 NUGGET CT
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2312
Practice Address - Country:US
Practice Address - Phone:818-314-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT817225XH1200X, 225XH1300X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT817OtherOT LICENSE