=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972512226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARISSA TORRES CRUZ P.T.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9700 DE SOTO AVE
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-882-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14634 GAULT ST #3
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91405-3049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-908-1153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | AT 3825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------