Provider Demographics
NPI:1003258039
Name:TAHERI, MIKAELA ANN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:ANN
Last Name:TAHERI
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 HAIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6427
Mailing Address - Country:US
Mailing Address - Phone:425-327-2787
Mailing Address - Fax:
Practice Address - Street 1:456 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3319
Practice Address - Country:US
Practice Address - Phone:760-740-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
308403OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
CA13394OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY