=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053015677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN GERALDINE INABA OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2023
-----------------------------------------------------
Last Update Date | 03/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1565 GLEN OAKS BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-376-5265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1565 GLEN OAKS BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-376-5265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 8374
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Occupational Therapist
-----------------------------------------------------
License Number | 8374
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XE0001X
-----------------------------------------------------
Taxonomy Name | Environmental Modification Occupational Therapist
-----------------------------------------------------
License Number | 8374
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------