Provider Demographics
NPI:1013682772
Name:ALFONSO, MICHELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 LEEWARD AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4407
Mailing Address - Country:US
Mailing Address - Phone:213-216-0683
Mailing Address - Fax:
Practice Address - Street 1:1180 N BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3301
Practice Address - Country:US
Practice Address - Phone:714-996-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5663224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant