MEDICARE: MS. VICKI LYNN BEANE 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

General Provider Information

NPI Number	:	1972726255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICKI LYNN BEANE OTR L

Provider Business Mailing Address
First Line	:	738 GREENWOOD AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-1008
Country	:	US
Telephone Number	:	909-880-1655
Fax Number	:

Provider Business Practice Location Address
First Line	:	9161 SIERRA AVE
Second Line	:	SUIET 111
City	:	FONTANA
State	:	CA
Zip	:	92335-4729
Country	:	US
Telephone Number	:	909-427-4073
Fax Number	:	909-427-4736

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	11/29/2021

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