Provider Demographics
NPI:1053646596
Name:ROMO, MIKELLE MONIQUE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MIKELLE
Middle Name:MONIQUE
Last Name:ROMO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MIKI
Other - Middle Name:
Other - Last Name:ROMO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1530 5TH AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1816
Mailing Address - Country:US
Mailing Address - Phone:415-457-7745
Mailing Address - Fax:415-453-9685
Practice Address - Street 1:1530 5TH AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1816
Practice Address - Country:US
Practice Address - Phone:415-457-7745
Practice Address - Fax:415-453-9685
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT5997225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics