Provider Demographics
NPI:1043867252
Name:DALSTROM, MICHAEL RAYMOND (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:DALSTROM
Suffix:
Gender:M
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 1:1332 KINGSFORD DR
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6133
Mailing Address - Country:US
Mailing Address - Phone:201-835-5384
Mailing Address - Fax:
Practice Address - Street 1:7807 UPLANDS WAY
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7500
Practice Address - Country:US
Practice Address - Phone:916-967-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17248225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist