Healthcare Provider Details

I. General information

NPI: 1104542257
Provider Name (Legal Business Name): JAPHETH MAICO OTD, OTR-L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6623 TOPLEY PIKE AVE
LAS VEGAS NV
89139-5391
US

IV. Provider business mailing address

6623 TOPLEY PIKE AVE
LAS VEGAS NV
89139-5391
US

V. Phone/Fax

Practice location:
  • Phone: 626-818-6947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: