Healthcare Provider Details

I. General information

NPI: 1881317907
Provider Name (Legal Business Name): ELISABETH RENEE BOLTEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11460 W WASHINGTON BLVD
LOS ANGELES CA
90066-6030
US

IV. Provider business mailing address

7709 W 85TH ST
PLAYA DEL REY CA
90293-8405
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax: 310-216-6153
Mailing address:
  • Phone: 310-903-3409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number24158
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number24158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: