Provider Demographics
NPI:1114474400
Name:KEPHART, ANGELEENA
Entity Type:Individual
Prefix:
First Name:ANGELEENA
Middle Name:
Last Name:KEPHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 NAPOLI DR
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4024
Mailing Address - Country:US
Mailing Address - Phone:714-323-4216
Mailing Address - Fax:
Practice Address - Street 1:500 W CENTRAL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3027
Practice Address - Country:US
Practice Address - Phone:714-323-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14864225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist