Basic Information
| Provider Information | |||||||||
| NPI: | 1720569254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLERBROCK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENT | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13685 STOWE DR STE A | ||||||||
| Address2: | |||||||||
| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920648824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583910052 | ||||||||
| FaxNumber: | 8583910053 | ||||||||
| Practice Location | |||||||||
| Address1: | 15720 BERNARDO CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586723900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | AA499095 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.