Healthcare Provider Details

I. General information

NPI: 1083198006
Provider Name (Legal Business Name): MARIAMME HANNA IBRAHIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 OVERLAND AVE
LOS ANGELES CA
90034-6311
US

IV. Provider business mailing address

3745 OVERLAND AVE
LOS ANGELES CA
90034-6311
US

V. Phone/Fax

Practice location:
  • Phone: 310-394-6889
  • Fax:
Mailing address:
  • Phone: 310-394-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number24781
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: