Healthcare Provider Details

I. General information

NPI: 1083942148
Provider Name (Legal Business Name): MARY ELLEN FLORENDO-TAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W SAN JOSE AVE
CLAREMONT CA
91711-5204
US

IV. Provider business mailing address

1524 E MAPLEGROVE ST
WEST COVINA CA
91792-1214
US

V. Phone/Fax

Practice location:
  • Phone: 909-621-2780
  • Fax:
Mailing address:
  • Phone: 909-615-6638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 1109
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License NumberOT1109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: