Provider Demographics
NPI:1942477997
Name:SYROTIAK, BOGUSLAWA TERESA
Entity Type:Individual
Prefix:MISS
First Name:BOGUSLAWA
Middle Name:TERESA
Last Name:SYROTIAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BOGUSLAWA
Other - Middle Name:TERESA
Other - Last Name:KELLOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:21802 MICHIGAN LANE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:626-831-8182
Mailing Address - Fax:
Practice Address - Street 1:16257 LAGUNA CANYON ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-727-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist