Provider Demographics
NPI:1669792982
Name:SCANLON, ELIZABETH GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:SCANLON
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 1:3731 SIXTH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:858-583-4993
Mailing Address - Fax:
Practice Address - Street 1:3731 SIXTH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:858-583-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225X00000X
CA12824225X00000X
OR275409225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist