Provider Demographics
NPI:1407168644
Name:SEYOUM, MESERET
Entity Type:Individual
Prefix:
First Name:MESERET
Middle Name:
Last Name:SEYOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8152 MANITOBA ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8681
Mailing Address - Country:US
Mailing Address - Phone:310-822-3986
Mailing Address - Fax:
Practice Address - Street 1:400 INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5061
Practice Address - Country:US
Practice Address - Phone:813-371-3421
Practice Address - Fax:800-677-4470
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1679225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679Medicaid