Provider Demographics
NPI:1619292323
Name:ITO, NAZUKI (MA, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:NAZUKI
Middle Name:
Last Name:ITO
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3216
Mailing Address - Country:US
Mailing Address - Phone:310-337-7115
Mailing Address - Fax:310-216-6153
Practice Address - Street 1:6315 ARIZONA PL
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1252
Practice Address - Country:US
Practice Address - Phone:310-337-7115
Practice Address - Fax:310-216-6153
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9655225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist