Provider Demographics
NPI:1861113318
Name:KADDIS, CHARISA (OTR/L)
Entity type:Individual
Prefix:
First Name:CHARISA
Middle Name:
Last Name:KADDIS
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 1:5792 ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2612
Mailing Address - Country:US
Mailing Address - Phone:714-514-8053
Mailing Address - Fax:
Practice Address - Street 1:4889 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90720-2690
Practice Address - Country:US
Practice Address - Phone:619-375-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26016225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist