Healthcare Provider Details

I. General information

NPI: 1043038847
Provider Name (Legal Business Name): SHAUNNA KOTKA OTD, OTR/L, CLT-LANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 MINDANAO WAY STE 211
MARINA DEL REY CA
90292-7942
US

IV. Provider business mailing address

13160 MINDANAO WAY STE 211
MARINA DEL REY CA
90292-7942
US

V. Phone/Fax

Practice location:
  • Phone: 310-882-0177
  • Fax: 844-688-0141
Mailing address:
  • Phone: 310-437-0932
  • Fax: 844-688-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number28299
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number28299
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number28299
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: