Provider Demographics
NPI:1730427089
Name:WALLUM, GARY (COTA/L)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WALLUM
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3812 PARK BLVD
Mailing Address - Street 2:UNIT 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3679
Mailing Address - Country:US
Mailing Address - Phone:619-770-8663
Mailing Address - Fax:
Practice Address - Street 1:3812 PARK BLVD
Practice Address - Street 2:UNIT 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3679
Practice Address - Country:US
Practice Address - Phone:619-770-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA58224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant