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General NPI Number Information
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NPI Number | 1861265928
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Entity Type | Individual
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Provider Name | RICHELLE MATIENZO PTA
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Gender | Female
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Dates
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Enumeration Date | 11/01/2023
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 3300 E SOUTH ST STE 203
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City | LAKEWOOD
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State | CA
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Zip | 90805-4589
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Country | US
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Telephone | 562-512-3320
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Fax |
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Provider Business Mailing Address
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Address Line | 8791 WALKER ST APT 34
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City | CYPRESS
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State | CA
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Zip | 90630-5916
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Country | US
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Telephone | 714-249-8132
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 52844
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License Number State | CA
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