Healthcare Provider Details

I. General information

NPI: 1417838145
Provider Name (Legal Business Name): ELIZABETH VILLANUEVA OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 N GRAND AVE
COVINA CA
91724-2046
US

IV. Provider business mailing address

943 N GRAND AVE
COVINA CA
91724-2046
US

V. Phone/Fax

Practice location:
  • Phone: 626-671-6100
  • Fax:
Mailing address:
  • Phone: 626-671-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number28101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: