=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790413144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CZARINA CATHERINE DE LEON RPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2022
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1575 E WASHINGTON BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91104-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-791-1981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 NORTHWOODS LN
-----------------------------------------------------
City | LA CRESCENTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91214-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-624-6357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 18325
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------