Provider Demographics
NPI:1649732645
Name:DEL MAR, MARYDEL DELGADO (OTR)
Entity type:Individual
Prefix:
First Name:MARYDEL
Middle Name:DELGADO
Last Name:DEL MAR
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 1:22519 HAWTHORNE BLVD SUITE F
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2509
Mailing Address - Country:US
Mailing Address - Phone:760-424-9123
Mailing Address - Fax:
Practice Address - Street 1:16617 FAYSMITH AVENUE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504
Practice Address - Country:US
Practice Address - Phone:760-424-9123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XE0001X
CA7753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification