Healthcare Provider Details

I. General information

NPI: 1003230368
Provider Name (Legal Business Name): ANDREW COLE BOCCTHY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 WILCOX AVE #305
LOS ANGELES CA
90038-3698
US

IV. Provider business mailing address

821 WILCOX AVE #305
LOS ANGELES CA
90038-3698
US

V. Phone/Fax

Practice location:
  • Phone: 805-704-3976
  • Fax:
Mailing address:
  • Phone: 805-704-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number10063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: