Healthcare Provider Details

I. General information

NPI: 1083052096
Provider Name (Legal Business Name): CORTLAND NOWLES WITHERSPOON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2767 E IMPERIAL HWY
BREA CA
92821-6713
US

IV. Provider business mailing address

939 AMHERST ST
CORONA CA
92878-4425
US

V. Phone/Fax

Practice location:
  • Phone: 714-578-8720
  • Fax:
Mailing address:
  • Phone: 909-230-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number33375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: