Provider Demographics
NPI:1801368972
Name:BOSTOCK, LAURA ANNE (MOT, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANNE
Last Name:BOSTOCK
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 JOSHUA TREE CT
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-5565
Mailing Address - Country:US
Mailing Address - Phone:805-405-7013
Mailing Address - Fax:
Practice Address - Street 1:5945 PACIFIC CENTER BLVD STE 510
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-6305
Practice Address - Country:US
Practice Address - Phone:858-695-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR380689225X00000X
UT10450587-4201225X00000X
CA17484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
380689OtherNBCOT - NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY