=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700284957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE MCCARTHY PHYSICAL THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2014
-----------------------------------------------------
Last Update Date | 12/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11835 W. OLYMPIC BLVD SUITE 135E
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-781-3388
-----------------------------------------------------
Fax | 888-798-0831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8726 S. SEPULVEDA BLVD SUITE D-271
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-781-3388
-----------------------------------------------------
Fax | 888-798-0831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHELLE MCCARTHY
-----------------------------------------------------
Credential | PT, DPT, OCS
-----------------------------------------------------
Telephone | 424-781-3388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 23396
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------