Provider Demographics
NPI:1720569254
Name:ELLERBROCK, KAREN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:ELLERBROCK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:13685 STOWE DR STE A
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-8824
Mailing Address - Country:US
Mailing Address - Phone:858-391-0052
Mailing Address - Fax:858-391-0053
Practice Address - Street 1:15720 BERNARDO CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-5861
Practice Address - Country:US
Practice Address - Phone:858-672-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAA499095225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist