Provider Demographics
NPI:1245628908
Name:TRABALLO, CHARLENE DELOS REYES (OTR/L)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:DELOS REYES
Last Name:TRABALLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 W GRAVES AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3826
Mailing Address - Country:US
Mailing Address - Phone:323-803-9980
Mailing Address - Fax:
Practice Address - Street 1:1035 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4138
Practice Address - Country:US
Practice Address - Phone:323-723-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10915225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist