Provider Demographics
NPI:1053571307
Name:AIRTH-EDBLOM, TRACEY L (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:AIRTH-EDBLOM
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PACIFIC DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-5479
Mailing Address - Country:US
Mailing Address - Phone:415-382-8202
Mailing Address - Fax:415-382-8212
Practice Address - Street 1:226 WELLER ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3136
Practice Address - Country:US
Practice Address - Phone:707-762-7678
Practice Address - Fax:707-762-7679
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT345225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand