Healthcare Provider Details

I. General information

NPI: 1003284993
Provider Name (Legal Business Name): MICHELLE OUATTARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

1540 ALCAZAR ST CHP-133
LOS ANGELES CA
90089-0080
US

V. Phone/Fax

Practice location:
  • Phone: 323-432-5080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number17059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: