Healthcare Provider Details

I. General information

NPI: 1639316904
Provider Name (Legal Business Name): GWENDOLINE R CUDIAMAT OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 WILSHIRE BLVD 211
LOS ANGELES CA
90010-1136
US

IV. Provider business mailing address

3000 WILSHIRE BLVD 211
LOS ANGELES CA
90010-1136
US

V. Phone/Fax

Practice location:
  • Phone: 213-738-0999
  • Fax:
Mailing address:
  • Phone: 213-738-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 9101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: