Provider Demographics
NPI:1669849428
Name:CARRICO, LAN (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAN
Middle Name:
Last Name:CARRICO
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 1:1301 W ARROW HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2330
Mailing Address - Country:US
Mailing Address - Phone:909-222-2745
Mailing Address - Fax:909-929-0805
Practice Address - Street 1:1301 W ARROW HWY
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2330
Practice Address - Country:US
Practice Address - Phone:909-222-2745
Practice Address - Fax:909-929-0805
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist