Provider Demographics
NPI:1144619255
Name:FONACIER, LEILANI BASILIO (MAOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:BASILIO
Last Name:FONACIER
Suffix:
Gender:F
Credentials:MAOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 S GLENNIE LN
Mailing Address - Street 2:APT F
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-1062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5710 S GLENNIE LN
Practice Address - Street 2:APT F
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-1062
Practice Address - Country:US
Practice Address - Phone:323-992-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist