Provider Demographics
NPI:1881340321
Name:ENRIQUEZ, NINA MARIE CANLAS (COTA/L)
Entity type:Individual
Prefix:
First Name:NINA MARIE
Middle Name:CANLAS
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N RAMPART BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3810
Mailing Address - Country:US
Mailing Address - Phone:213-587-0280
Mailing Address - Fax:
Practice Address - Street 1:5310 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1005
Practice Address - Country:US
Practice Address - Phone:323-461-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA467269224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant