=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053520924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSANA MORELL DORNBERG OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 12/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2040 PACIFIC COAST HWY
-----------------------------------------------------
City | LOMITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90717-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-920-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 218 VIA LA SOLEDAD
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90277-6626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-920-2302
-----------------------------------------------------
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 | OT 4667
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------