Healthcare Provider Details

I. General information

NPI: 1972726255
Provider Name (Legal Business Name): VICKI LYNN BEANE OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9161 SIERRA AVE SUIET 111
FONTANA CA
92335-4729
US

IV. Provider business mailing address

738 GREENWOOD AVE
SAN BERNARDINO CA
92407-1008
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-4073
  • Fax: 909-427-4736
Mailing address:
  • Phone: 909-880-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: