Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT5997 | CA |
NPI | 1053646596 |
---|---|
Provider Name | Mrs. Mikelle Monique Romo |
First Address | San Rafael, CA 94901-1816 |
Second Address | San Rafael, CA 94901-1816 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2009 |
Last Update Date | 15/10/2009 |