Healthcare Provider Details

I. General information

NPI: 1265707764
Provider Name (Legal Business Name): MARIA DONNA BALTAZAR MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BEACH BLVD
ANAHEIM CA
92804-1810
US

IV. Provider business mailing address

1780 W LINCOLN AVE APT 333
ANAHEIM CA
92801-6760
US

V. Phone/Fax

Practice location:
  • Phone: 714-816-0540
  • Fax:
Mailing address:
  • Phone: 562-455-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT 10247
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT 10247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: