Provider Demographics
NPI:1699230649
Name:GASTELLUM, ELYSSA JEAN (COTA/L)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:JEAN
Last Name:GASTELLUM
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 1:3704 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3413
Mailing Address - Country:US
Mailing Address - Phone:805-757-3108
Mailing Address - Fax:
Practice Address - Street 1:249 E OCEAN BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4806
Practice Address - Country:US
Practice Address - Phone:888-808-7838
Practice Address - Fax:866-620-3943
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4720224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant