=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487235248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPLAY LA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2021
-----------------------------------------------------
Last Update Date | 04/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1070 S LA BREA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019-6905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-630-9084
-----------------------------------------------------
Fax | 424-442-0298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1070 S LA BREA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019-6905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-630-9084
-----------------------------------------------------
Fax | 424-442-0298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DR. MARIELLY MITCHELL
-----------------------------------------------------
Credential | DOCTOR OF OT
-----------------------------------------------------
Telephone | 310-630-9084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------