Healthcare Provider Details

I. General information

NPI: 1316287246
Provider Name (Legal Business Name): SHUREE GANGLOFF SMOCK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHUREE N/A GANGLOFF PT, DPT

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD SUITE 302
PASADENA CA
91105-2544
US

IV. Provider business mailing address

PO BOX 50004
PASADENA CA
91115-0004
US

V. Phone/Fax

Practice location:
  • Phone: 626-683-8236
  • Fax: 626-683-8236
Mailing address:
  • Phone: 626-683-8536
  • Fax: 626-683-8236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: