Provider Demographics
NPI:1619576832
Name:PHELPS, GEORGINA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3139
Mailing Address - Country:US
Mailing Address - Phone:626-372-5651
Mailing Address - Fax:
Practice Address - Street 1:2001 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-3622
Practice Address - Country:US
Practice Address - Phone:626-372-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4581225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health