Basic Information
| Provider Information | |||||||||
| NPI: | 1326514738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SQUILLACE | ||||||||
| FirstName: | MIRELLA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10620 BALBOA BLVD APT 117 | ||||||||
| Address2: | |||||||||
| City: | GRANADA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913446333 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189070952 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2018 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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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 | 225200000X | 48873 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.