Healthcare Provider Details

I. General information

NPI: 1831643949
Provider Name (Legal Business Name): THERA-BRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E VERDUGO AVE APT J
BURBANK CA
91501-2373
US

IV. Provider business mailing address

603 E VERDUGO AVE APT J
BURBANK CA
91501-2373
US

V. Phone/Fax

Practice location:
  • Phone: 818-748-7066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number13092
License Number StateCA

VIII. Authorized Official

Name: MARY ANNTHONETTE DE GUZMAN
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 818-748-7066