MEDICARE: WELLNESS INTERPROFESSIONAL PHYSICAL THERAPY CORPORATION, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	53973	CA
2	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	87429	CA
3	1223G0001X	General Practice Dentistry	63162	CA
4	106H00000X	Marriage & Family Therapist	80856	CA
5	364SA2200X	Adult Health Clinical Nurse Specialist	22533	CA
6	2251N0400X	Neurology Physical Therapist	14280	CA
7	2251P0200X	Pediatric Physical Therapist	40379	CA
8	2251G0304X	Geriatric Physical Therapist	15587	CA
9	1223G0001X	General Practice Dentistry	44450	CA
10	261QM1300X	Multi-Specialty Clinic/Center	14280	CA

General Provider Information

NPI Number	:	1134535750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS INTERPROFESSIONAL PHYSICAL THERAPY CORPORATION, PC

Provider Business Mailing Address
First Line	:	3501 W JEFFERSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-3237
Country	:	US
Telephone Number	:	323-730-1205
Fax Number	:	213-221-4778

Provider Business Practice Location Address
First Line	:	3501 W JEFFERSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-3237
Country	:	US
Telephone Number	:	323-730-1205
Fax Number	:	213-221-4778

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. KATHERINE JOSEPHINE SULLIVAN
Credential	:	P.T.
Telephone Number	:	323-730-1205

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	05/18/2016

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