Healthcare Provider Details

I. General information

NPI: 1760104715
Provider Name (Legal Business Name): TALYA DANIELLE CISNEROS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TALYA GLASS

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26302 LA PAZ RD STE 105
MISSION VIEJO CA
92691-5327
US

IV. Provider business mailing address

21 PALAZZO
NEWPORT BEACH CA
92660-9106
US

V. Phone/Fax

Practice location:
  • Phone: 949-206-1700
  • Fax:
Mailing address:
  • Phone: 949-230-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: