Provider Demographics
NPI:1477316875
Name:MAICO, MARIAH MYRNA LONTOK (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIAH MYRNA
Middle Name:LONTOK
Last Name:MAICO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 W BEVERLY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4265
Mailing Address - Country:US
Mailing Address - Phone:562-927-5820
Mailing Address - Fax:
Practice Address - Street 1:3680 IMPERIAL HWY
Practice Address - Street 2:3RD FLOOR, SUITE 350
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-220-6108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT10397225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist