Provider Demographics
NPI:1316329311
Name:TAN, LILY (OTR/L)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:TAN
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 1:639 N BROADWAY
Mailing Address - Street 2:APT 434
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-4500
Mailing Address - Country:US
Mailing Address - Phone:702-321-0806
Mailing Address - Fax:
Practice Address - Street 1:639 N BROADWAY
Practice Address - Street 2:APT 434
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-4500
Practice Address - Country:US
Practice Address - Phone:702-321-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15113225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist