Provider Demographics
NPI:1932627700
Name:FINE, BRIANNA MICHELLE (MSOT, OTR/L, CPAM)
Entity Type:Individual
Prefix:MRS
First Name:BRIANNA
Middle Name:MICHELLE
Last Name:FINE
Suffix:
Gender:F
Credentials:MSOT, OTR/L, CPAM
Other - Prefix:MISS
Other - First Name:BRIANNA
Other - Middle Name:MICHELLE
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOT, OTR/L
Mailing Address - Street 1:1130 S PATTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3429
Mailing Address - Country:US
Mailing Address - Phone:310-429-8580
Mailing Address - Fax:
Practice Address - Street 1:1955 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1807
Practice Address - Country:US
Practice Address - Phone:310-325-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT11399225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT11399OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY