=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558954131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ECKERT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2021
-----------------------------------------------------
Last Update Date | 02/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5359 BALBOA BLVD STE A
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-849-5396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1071 BRITTEN LN APT 108
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-8209
-----------------------------------------------------
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 | 21404
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------