Individual
ED A DETELS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OT
Contact information
Practice address
200 NEWPORT CENTER DR, #213, NEWPORT BEACH, CA 92660-7501
(949) 644-1322
(949) 644-0316
Mailing address
200 NEWPORT CENTER DR, #213, NEWPORT BEACH, CA 92660-7501
(949) 644-1322
(949) 644-0316
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT1096
CA
Other
Enumeration date
12/12/2005
Last updated
10/18/2012
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