Healthcare Provider Details

I. General information

NPI: 1356006837
Provider Name (Legal Business Name): AVERY VICE OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 W MAGNOLIA BLVD
BURBANK CA
91505-3031
US

IV. Provider business mailing address

9246 LIGHTWAVE AVE STE 120
SAN DIEGO CA
92123-6411
US

V. Phone/Fax

Practice location:
  • Phone: 800-270-5016
  • Fax: 800-680-3626
Mailing address:
  • Phone: 800-270-5016
  • Fax: 800-680-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT22803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: