Healthcare Provider Details

I. General information

NPI: 1427009935
Provider Name (Legal Business Name): VENESSA D VIGIL O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2888 LONG BEACH BLVD #405
LONG BEACH CA
90806-1530
US

IV. Provider business mailing address

200 NEWPORT CENTER DR #213
NEWPORT BEACH CA
92660-7501
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-4489
  • Fax: 562-595-4063
Mailing address:
  • Phone: 949-644-1322
  • Fax: 949-644-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 6928
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: