Healthcare Provider Details

I. General information

NPI: 1750887865
Provider Name (Legal Business Name): JUDY THUY LU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

IV. Provider business mailing address

6712 CAPPS AVE
RESEDA CA
91335-5208
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-2276
  • Fax:
Mailing address:
  • Phone: 818-401-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number18608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: