Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 9727 | CA |
NPI | 1013399922 |
---|---|
Provider Name | Ivory Tifa |
First Address | Beaumont, CA 92223-7190 |
Second Address | Beaumont, CA 92223-7190 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2015 |
Last Update Date | 26/06/2015 |