Provider Demographics
NPI:1588324511
Name:SISOWATH, VIKAVATDEI LESLIE (OTR/L)
Entity type:Individual
Prefix:
First Name:VIKAVATDEI
Middle Name:LESLIE
Last Name:SISOWATH
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 1:8252 SOMERDALE LN
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1938
Mailing Address - Country:US
Mailing Address - Phone:714-458-1495
Mailing Address - Fax:
Practice Address - Street 1:5901 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90822-5201
Practice Address - Country:US
Practice Address - Phone:562-826-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21504225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist