Provider Demographics
NPI:1972326395
Name:SMIDA, MAGGIE PESTA (OTR/L)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:PESTA
Last Name:SMIDA
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 1:24 VINE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2730
Mailing Address - Country:US
Mailing Address - Phone:415-302-3203
Mailing Address - Fax:
Practice Address - Street 1:24 VINE AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2730
Practice Address - Country:US
Practice Address - Phone:415-302-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11758225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist