Provider Demographics
NPI:1205386752
Name:CODILLA, ALEXIS MARIE
Entity Type:Individual
Prefix:
First Name:ALEXIS MARIE
Middle Name:
Last Name:CODILLA
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 1:6752 LEANNE ST
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6752 LEANNE ST
Practice Address - Street 2:
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-3476
Practice Address - Country:US
Practice Address - Phone:951-427-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-08
Last Update Date:2016-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3681224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant