Provider Demographics
NPI:1750156824
Name:ALFONSO, MICHELLE (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ALFONSO
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 1:1616 247TH ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2061
Mailing Address - Country:US
Mailing Address - Phone:310-951-0469
Mailing Address - Fax:
Practice Address - Street 1:1929 N FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2205
Practice Address - Country:US
Practice Address - Phone:714-554-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist