Healthcare Provider Details

I. General information

NPI: 1134535750
Provider Name (Legal Business Name): WELLNESS INTERPROFESSIONAL PHYSICAL THERAPY CORPORATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W JEFFERSON BLVD
LOS ANGELES CA
90018-3237
US

IV. Provider business mailing address

3501 W JEFFERSON BLVD
LOS ANGELES CA
90018-3237
US

V. Phone/Fax

Practice location:
  • Phone: 323-730-1205
  • Fax: 213-221-4778
Mailing address:
  • Phone: 323-730-1205
  • Fax: 213-221-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53973
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number87429
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63162
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number80856
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number22533
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number14280
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number40379
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number15587
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44450
License Number StateCA
# 10
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number14280
License Number StateCA

VIII. Authorized Official

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