MEDICARE: MS. POLIN DERBARSEGHIAN OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	19070	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19070	OTHER	CA	CBOT

General Provider Information

NPI Number	:	1568038982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. POLIN DERBARSEGHIAN OTR/L

Provider Business Mailing Address
First Line	:	250 E OLIVE AVE STE 202A
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 E OLIVE AVE STE 202A
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1211
Country	:	US
Telephone Number	:	747-231-7708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/27/2021

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