Provider Demographics
NPI:1366258196
Name:TINKELENBERG, MIMI ANTONIA STROUD (OT)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:ANTONIA STROUD
Last Name:TINKELENBERG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:ANTONIA STROUD
Other - Last Name:STROUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:3400 I ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4570
Mailing Address - Country:US
Mailing Address - Phone:661-619-1907
Mailing Address - Fax:
Practice Address - Street 1:855 HOWE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3912
Practice Address - Country:US
Practice Address - Phone:661-619-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21151225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist