Healthcare Provider Details

I. General information

NPI: 1205226677
Provider Name (Legal Business Name): BRENDA CAPUA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 LUTHER DR
SPRING VALLEY CA
91977-5262
US

IV. Provider business mailing address

938 LUTHER DR
SPRING VALLEY CA
91977-5262
US

V. Phone/Fax

Practice location:
  • Phone: 619-474-6741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: