Provider Demographics
NPI:1346656014
Name:DARAVONG, ANASTASIA FE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ANASTASIA
Middle Name:FE
Last Name:DARAVONG
Suffix:
Gender:F
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 1:1130 S. WOODMAN ST
Mailing Address - Street 2:APT 14
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114
Mailing Address - Country:US
Mailing Address - Phone:619-243-6183
Mailing Address - Fax:
Practice Address - Street 1:7850 MISSION CENTER CT
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1322
Practice Address - Country:US
Practice Address - Phone:619-578-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2660224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant