Basic Information
| Provider Information | |||||||||
| NPI: | 1801368972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTOCK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 JOSHUA TREE CT | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925705565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054057013 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5945 PACIFIC CENTER BLVD STE 510 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921216305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586959444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2018 | ||||||||
| LastUpdateDate: | 12/29/2018 | ||||||||
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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 | 380689 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 10450587-4201 | UT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 17484 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 380689 | 01 | NBCOT - NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY | OTHER |