Provider Demographics
NPI:1457083792
Name:WAN, GRACE (COTA/L)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WAN
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 1:1362 N SCHOONER LN
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1778
Mailing Address - Country:US
Mailing Address - Phone:480-278-1030
Mailing Address - Fax:
Practice Address - Street 1:140 S CHAPARRAL CT STE 160
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-2283
Practice Address - Country:US
Practice Address - Phone:714-794-5889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5957224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant