Provider Demographics
NPI:1376317552
Name:QIU, MARY JOSHNELLE EBREO (OT)
Entity Type:Individual
Prefix:
First Name:MARY JOSHNELLE
Middle Name:EBREO
Last Name:QIU
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 BIRCH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2226
Mailing Address - Country:US
Mailing Address - Phone:949-955-0010
Mailing Address - Fax:505-955-0033
Practice Address - Street 1:3900 BIRCH ST STE 103
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2226
Practice Address - Country:US
Practice Address - Phone:949-955-0010
Practice Address - Fax:505-955-0033
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21014225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist