Healthcare Provider Details

I. General information

NPI: 1306402615
Provider Name (Legal Business Name): TOMMY ANTWAN ELLERBE OTR / L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date: 11/06/2021
Reactivation Date: 08/31/2026

III. Provider practice location address

28924 S WESTERN AVE STE 105
RANCHO PALOS VERDES CA
90275-0823
US

IV. Provider business mailing address

28924 S WESTERN AVE STE 105
RANCHO PALOS VERDES CA
90275-0823
US

V. Phone/Fax

Practice location:
  • Phone: 424-210-8583
  • Fax:
Mailing address:
  • Phone: 424-210-8583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4758
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number29244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: