Provider Demographics
NPI:1588046007
Name:PICACHE, MYLAH BUENAVENTURA (OTR)
Entity Type:Individual
Prefix:
First Name:MYLAH
Middle Name:BUENAVENTURA
Last Name:PICACHE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MYLAH
Other - Middle Name:ESPIRITU
Other - Last Name:BUENAVENTURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:2149 ABRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3542
Mailing Address - Country:US
Mailing Address - Phone:818-648-7796
Mailing Address - Fax:
Practice Address - Street 1:2149 ABRAHAM ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3542
Practice Address - Country:US
Practice Address - Phone:818-648-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18900Medicare PIN