Healthcare Provider Details

I. General information

NPI: 1730383506
Provider Name (Legal Business Name): SUSAN MAIS-REQUEJO D.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 JOSIE AVE
LONG BEACH CA
90815-1515
US

IV. Provider business mailing address

2819 JOSIE AVE
LONG BEACH CA
90815-1515
US

V. Phone/Fax

Practice location:
  • Phone: 562-743-3761
  • Fax: 596-496-3628
Mailing address:
  • Phone: 562-743-3761
  • Fax: 596-496-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT18717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: