Basic Information
| Provider Information | |||||||||
| NPI: | 1093727794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETHLOFF | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | DEANNE | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 KUEHNER DR | ||||||||
| Address2: | #115 | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930633900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058238200 | ||||||||
| FaxNumber: | 8058238208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 KUEHNER DR | ||||||||
| Address2: | #115 | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930633900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058238200 | ||||||||
| FaxNumber: | 8058238208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 03/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT24002 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.