Healthcare Provider Details

I. General information

NPI: 1124269667
Provider Name (Legal Business Name): LANI ESPE VAN VLEIT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GUADALEA LANI ESPE VAN VLEIT OTR/L

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 W MACARTHUR BLVD BROADWAY MOB 2ND FLOOR, SUITE 201
OAKLAND CA
94611-5642
US

IV. Provider business mailing address

914 CHELTENHAM RD
SANTA BARBARA CA
93105-2234
US

V. Phone/Fax

Practice location:
  • Phone: 310-714-3795
  • Fax:
Mailing address:
  • Phone: 310-714-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2781
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1028133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: