Provider Demographics
NPI:1356572259
Name:REESE, MANDY RAE (OTR/L)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:RAE
Last Name:REESE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 AVENIDA ACAPULCO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2405
Mailing Address - Country:US
Mailing Address - Phone:949-388-0614
Mailing Address - Fax:
Practice Address - Street 1:1120 VIA CALLEJON STE B
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6264
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3877225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics