Provider Demographics
NPI:1477154011
Name:INNOVATIVE OCCUPATIONAL THERAPY
Entity Type:Organization
Organization Name:INNOVATIVE OCCUPATIONAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:KEYJONN
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:213-787-4301
Mailing Address - Street 1:1323 S CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE CAROLYN PKWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-4701
Practice Address - Country:US
Practice Address - Phone:213-787-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty