=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790525038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAMATA A PATEL OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2024
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 E HIGHLAND AVE
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-6233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-793-2678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15568 CARAVELLE AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-334-0647
-----------------------------------------------------
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 | 26478
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------