Basic Information
| Provider Information | |||||||||
| NPI: | 1760036685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAGAICH | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | MIYUKI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOSHIDA | ||||||||
| OtherFirstName: | MARI | ||||||||
| OtherMiddleName: | MIYUKI | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5910 N MUSCATEL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917752621 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12411 SLAUSON AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906062835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626935449 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2019 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 20259 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.