Healthcare Provider Details

I. General information

NPI: 1215911235
Provider Name (Legal Business Name): DANIELLE THEONE WISWALL MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 VULCAN DR
LOMPOC CA
93436
US

IV. Provider business mailing address

177 VULCAN DR
LOMPOC CA
93436
US

V. Phone/Fax

Practice location:
  • Phone: 805-733-7500
  • Fax: 805-733-7510
Mailing address:
  • Phone: 805-733-7500
  • Fax: 805-733-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26136
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPT0261360
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSBHI
# 2
IdentifierPT0261360
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerMEDI-CAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: