=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831643949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERA-BRIDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2016
-----------------------------------------------------
Last Update Date | 08/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 E VERDUGO AVE APT J
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91501-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-748-7066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 E VERDUGO AVE APT J
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91501-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MARY ANNTHONETTE DE GUZMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-748-7066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 13092
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------