Provider Demographics
NPI:1861082539
Name:BAILEY, TANAWAJA (OTR/L)
Entity type:Individual
Prefix:
First Name:TANAWAJA
Middle Name:
Last Name:BAILEY
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 1:575 E HARDY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4040
Mailing Address - Country:US
Mailing Address - Phone:310-412-0100
Mailing Address - Fax:310-412-0110
Practice Address - Street 1:575 E HARDY ST STE 105
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4040
Practice Address - Country:US
Practice Address - Phone:310-412-0100
Practice Address - Fax:310-412-0110
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT7253225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist