Provider Demographics
NPI:1053016212
Name:MOSCOSO, OLIVIA SUNSHYNE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SUNSHYNE
Last Name:MOSCOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 MONTANA DEL LAGO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1356
Mailing Address - Country:US
Mailing Address - Phone:949-633-4474
Mailing Address - Fax:
Practice Address - Street 1:36 MAUCHLY STE A
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2390
Practice Address - Country:US
Practice Address - Phone:949-727-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6294224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant