Provider Demographics
NPI:1477942233
Name:IWANICKI, CYNTHIA (OTR)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:IWANICKI
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 1:69472 SERENITY RD
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7921
Mailing Address - Country:US
Mailing Address - Phone:714-334-9788
Mailing Address - Fax:866-225-9947
Practice Address - Street 1:941 CROCUS CIR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1708
Practice Address - Country:US
Practice Address - Phone:714-334-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2523225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist