Healthcare Provider Details

I. General information

NPI: 1972637643
Provider Name (Legal Business Name): TONIA ELISA MUTLAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N ORANGE GROVE BLVD
PASADENA CA
91103-3333
US

IV. Provider business mailing address

480 WESTGATE ST
PASADENA CA
91103-2821
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-3453
  • Fax: 626-744-3411
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: