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General NPI Number Information
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NPI Number | 1477887321
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Entity Type | Individual
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Provider Name | MAILA TIBBERTS P.T.
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Gender | Female
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Dates
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Enumeration Date | 09/24/2009
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | 12113 SANTA MONICA BLVD SUITE 203
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City | LOS ANGELES
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State | CA
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Zip | 90025-2581
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Country | US
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Telephone | 310-309-3721
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Fax |
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Provider Business Mailing Address
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Address Line | 4640 CANEEL BAY CT
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City | OCEANSIDE
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State | CA
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Zip | 92057-4223
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Country | US
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Telephone | 109-566-1053
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 031126-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT 36737
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License Number State | CA
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