Healthcare Provider Details

I. General information

NPI: 1215449558
Provider Name (Legal Business Name): PATRICIA ANNE HALLIWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST RM 2199
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

1720 E 120TH ST RM 2199
LOS ANGELES CA
90059-3052
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-2444
  • Fax: 310-668-4103
Mailing address:
  • Phone: 424-338-2444
  • Fax: 310-668-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number10381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: