Provider Demographics
NPI:1700161015
Name:MITCHELL, MARIELLY ELIZABETH (MA, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARIELLY
Middle Name:ELIZABETH
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3216
Mailing Address - Country:US
Mailing Address - Phone:310-630-9084
Mailing Address - Fax:310-216-6153
Practice Address - Street 1:8717 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3216
Practice Address - Country:US
Practice Address - Phone:310-630-9084
Practice Address - Fax:310-216-6153
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 12156225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT 12156OtherOCCUPATIONAL THERAPY STATE LICENSE