Provider Demographics
NPI:1912562042
Name:WALL, REBECCA MARIE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:WALL
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 1:1236 10TH ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4347
Mailing Address - Country:US
Mailing Address - Phone:858-774-3159
Mailing Address - Fax:
Practice Address - Street 1:1815 W 213TH ST STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2852
Practice Address - Country:US
Practice Address - Phone:310-328-0276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19778225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist