Healthcare Provider Details

I. General information

NPI: 1366990871
Provider Name (Legal Business Name): MEENADCHI GUNANAYAGAM OTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 S ROBERTSON BLVD
LOS ANGELES CA
90035-3414
US

IV. Provider business mailing address

155 N OCCIDENTAL BLVD
LOS ANGELES CA
90026-4641
US

V. Phone/Fax

Practice location:
  • Phone: 310-785-2121
  • Fax:
Mailing address:
  • Phone: 213-381-2931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License NumberOT18362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: