Provider Demographics
NPI:1407513716
Name:MAURICIO, VANESSA RAE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RAE
Last Name:MAURICIO
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 1:7659 MISSION GORGE RD UNIT 87
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-1358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8840 N MAGNOLIA AVE STE 220
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4516
Practice Address - Country:US
Practice Address - Phone:619-749-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist