Provider Demographics
NPI:1083942148
Name:FLORENDO-TAN, MARY ELLEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:FLORENDO-TAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 E MAPLEGROVE ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1214
Mailing Address - Country:US
Mailing Address - Phone:909-615-6638
Mailing Address - Fax:
Practice Address - Street 1:140 W SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5204
Practice Address - Country:US
Practice Address - Phone:909-621-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1109225XF0002X
CAOT 1109225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing