Provider Demographics
NPI:1972620128
Name:WACHOLDER-SIEGAL, SHIRA RHONDA (OTR)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:RHONDA
Last Name:WACHOLDER-SIEGAL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2809
Mailing Address - Country:US
Mailing Address - Phone:323-559-0081
Mailing Address - Fax:323-931-8677
Practice Address - Street 1:9730 WILSHIRE BLVD. SUITE 200
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2004
Practice Address - Country:US
Practice Address - Phone:310-278-0204
Practice Address - Fax:310-278-0171
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT773225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT773Medicare ID - Type Unspecified