Basic Information
| Provider Information | |||||||||
| NPI: | 1881317907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTEN | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7709 W 85TH ST | ||||||||
| Address2: | |||||||||
| City: | PLAYA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902938405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109033409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11460 W WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900666030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103377115 | ||||||||
| FaxNumber: | 3102166153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2022 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 24158 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 24158 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.