Healthcare Provider Details

I. General information

NPI: 1689046443
Provider Name (Legal Business Name): MELISSA LAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 AVENIDA DEL MEXICO UNIT 244
SAN DIEGO CA
92154-1255
US

IV. Provider business mailing address

1945 AVENIDA DEL MEXICO UNIT 244
SAN DIEGO CA
92154-1255
US

V. Phone/Fax

Practice location:
  • Phone: 407-202-7378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: