Basic Information
| Provider Information | |||||||||
| NPI: | 1275987398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAR | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | TRICIA MEIJUN | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 LAS FLORES AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MARINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911081615 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12411 SLAUSON AVE | ||||||||
| Address2: | UNIT H | ||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906062835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626935449 | ||||||||
| FaxNumber: | 5626935469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 16071 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.