Provider Demographics
NPI:1427033604
Name:DETELS, ED A (OT)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:A
Last Name:DETELS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:200 NEWPORT CENTER DR
Practice Address - Street 2:#213
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7501
Practice Address - Country:US
Practice Address - Phone:949-644-1322
Practice Address - Fax:949-644-0316
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAEX552ZMedicare PIN
CAWOT1096AMedicare PIN