=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518391630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL WILLIAM GRAGNANI MA, OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2013
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 822 S ROBERTSON BLVD STE 202
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-910-4305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10422 HEBRON LN
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90077-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 15083
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------