Healthcare Provider Details

I. General information

NPI: 1275412074
Provider Name (Legal Business Name): PATHWAY PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12130 OHIO AVE APT 311
LOS ANGELES CA
90025-2580
US

IV. Provider business mailing address

12130 OHIO AVE APT 311
LOS ANGELES CA
90025-2580
US

V. Phone/Fax

Practice location:
  • Phone: 520-406-4128
  • Fax:
Mailing address:
  • Phone: 520-406-4128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACI HARRIS
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 520-406-4128