Provider Demographics
NPI:1063283034
Name:VON KLUEGL, MARYANN (COTA)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:VON KLUEGL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 COTTONWOOD AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-6705
Mailing Address - Country:US
Mailing Address - Phone:619-249-1597
Mailing Address - Fax:
Practice Address - Street 1:10538 MISSION GORGE RD STE 130
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3154
Practice Address - Country:US
Practice Address - Phone:619-312-6109
Practice Address - Fax:619-312-6110
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6560224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant