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NPI Code Detail

MEDICARE: EMMANUEL LICUP PT, DPT

MEDICARE: EMMANUEL LICUP PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist301922CA

General Provider Information

NPI Number : 1215679352
Entity Type Code : Individual
Provider Name (Legal Business Name) : EMMANUEL LICUP PT, DPT
Provider Business Mailing Address
First Line : 701 N YUCCA RIDGE RD
Second Line :
City : GLENDORA
State : CA
Zip : 91741-1884
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2550 N HOLLYWOOD WAY STE 100
Second Line :
City : BURBANK
State : CA
Zip : 91505-5015
Country : US
Telephone Number : 818-524-3730
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2022
Last Update Date : 04/09/2022

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Directions to “ EMMANUEL LICUP PT, DPT” Practice Location

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