Provider Demographics
NPI:1225488935
Name:NODALO, NATHANIEL (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:NODALO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1326
Mailing Address - Country:US
Mailing Address - Phone:310-951-2697
Mailing Address - Fax:
Practice Address - Street 1:11900 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4039
Practice Address - Country:US
Practice Address - Phone:562-865-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist