Provider Demographics
NPI:1275987398
Name:MAR, KELLY TRICIA MEIJUN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TRICIA MEIJUN
Last Name:MAR
Suffix:
Gender:F
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 1:1615 LAS FLORES AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12411 SLAUSON AVE
Practice Address - Street 2:UNIT H
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2835
Practice Address - Country:US
Practice Address - Phone:562-693-5449
Practice Address - Fax:562-693-5469
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist