Healthcare Provider Details

I. General information

NPI: 1972068096
Provider Name (Legal Business Name): LEONIE B KAWAGUCHI COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEONIE B CAPULONG

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N BREA BLVD
BREA CA
92821-2606
US

IV. Provider business mailing address

15334 GOODHUE ST
WHITTIER CA
90604-2320
US

V. Phone/Fax

Practice location:
  • Phone: 714-529-6842
  • Fax:
Mailing address:
  • Phone: 626-378-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: