Provider Demographics
NPI:1144792193
Name:HIDALGO, ALONZO RAFAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:RAFAEL
Last Name:HIDALGO
Suffix:
Gender:M
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 1:909 S FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2625
Mailing Address - Country:US
Mailing Address - Phone:626-389-9515
Mailing Address - Fax:
Practice Address - Street 1:909 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2625
Practice Address - Country:US
Practice Address - Phone:626-389-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19402225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist