Healthcare Provider Details

I. General information

NPI: 1548190952
Provider Name (Legal Business Name): LITTLE TRAILBLAZERS OT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3078 BROADWAY UNIT 203
SAN DIEGO CA
92102-2348
US

IV. Provider business mailing address

3078 BROADWAY UNIT 203
SAN DIEGO CA
92102-2348
US

V. Phone/Fax

Practice location:
  • Phone: 763-226-1407
  • Fax:
Mailing address:
  • Phone: 763-226-1407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA MOUANNES
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 763-226-1407