Healthcare Provider Details

I. General information

NPI: 1891591905
Provider Name (Legal Business Name): HAYLIE W MICELI OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HAYLIE K WONG

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 MARENGO ST STE 500
LOS ANGELES CA
90033-1061
US

IV. Provider business mailing address

PO BOX 50938
LOS ANGELES CA
90074-0938
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-3340
  • Fax:
Mailing address:
  • Phone: 323-442-3340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT29467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: