Provider Demographics
NPI:1326300351
Name:GAN, LEEANN MARIE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:LEEANN
Middle Name:MARIE
Last Name:GAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17609 VENTURA BLVD
Mailing Address - Street 2:SUITE #215
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3858
Mailing Address - Country:US
Mailing Address - Phone:818-530-5116
Mailing Address - Fax:818-501-8325
Practice Address - Street 1:17609 VENTURA BLVD
Practice Address - Street 2:SUITE #215
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3858
Practice Address - Country:US
Practice Address - Phone:818-530-5116
Practice Address - Fax:818-501-8325
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2100224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant