Provider Demographics
NPI:1508377227
Name:EAGLESON, CELICA KIDO (COTA/L)
Entity Type:Individual
Prefix:
First Name:CELICA
Middle Name:KIDO
Last Name:EAGLESON
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 1:2125 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1705
Mailing Address - Country:US
Mailing Address - Phone:310-430-0597
Mailing Address - Fax:
Practice Address - Street 1:947 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-2508
Practice Address - Country:US
Practice Address - Phone:310-430-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3247224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant