Healthcare Provider Details

I. General information

NPI: 1780291328
Provider Name (Legal Business Name): MAXINE ARIEL LEDET OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 E FOOTHILL BLVD
SAN DIMAS CA
91773-1209
US

IV. Provider business mailing address

941 W 47TH ST
LOS ANGELES CA
90037-2948
US

V. Phone/Fax

Practice location:
  • Phone: 334-439-9379
  • Fax:
Mailing address:
  • Phone: 334-439-9379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number21560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: