Provider Demographics
NPI:1962565143
Name:BRUCE, MARY ANN (PHD, OTR,L)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:PHD, OTR,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25971 PALA
Mailing Address - Street 2:STE 110
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2742
Mailing Address - Country:US
Mailing Address - Phone:949-465-9500
Mailing Address - Fax:
Practice Address - Street 1:25971 PALA
Practice Address - Street 2:STE 110
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2742
Practice Address - Country:US
Practice Address - Phone:949-465-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT142225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOT142AMedicare ID - Type UnspecifiedPPIN