MEDICARE: AQUATIC THERAPY ASSOCIATES

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
1	225100000X	Physical Therapist	PT16863	CA

General Provider Information

NPI Number	:	1972632172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUATIC THERAPY ASSOCIATES

Provider Business Mailing Address
First Line	:	4460 16 REDWOOD HWY #404
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N SAN PEDRO RD
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-4213
Country	:	US
Telephone Number	:	415-507-9800
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CARYL SIRCUS
Credential	:
Telephone Number	:	415-507-9800

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	08/22/2020

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