Provider Demographics
NPI:1962415877
Name:WOLFE, MARY KAY (OTD,OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:WOLFE
Suffix:
Gender:F
Credentials:OTD,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2250 ALCAZAR ST
Practice Address - Street 2:CSC-133
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0229
Practice Address - Country:US
Practice Address - Phone:323-442-3340
Practice Address - Fax:323-442-3351
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT6242225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT6242OtherLICENSE
CA954454491OtherTAX ID#