Basic Information
| Provider Information | |||||||||
| NPI: | 1356355028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDENAS | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13116 E MILLERTON RD | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930212141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109244233 | ||||||||
| FaxNumber: | 8057331213 | ||||||||
| Practice Location | |||||||||
| Address1: | 2876 SYCAMORE DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930651550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052105787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT16081 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT16081 | 01 | CA | PHYSICAL THERAPY LICENSE | OTHER |