Basic Information
| Provider Information | |||||||||
| NPI: | 1396799953 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WYTE | ||||||||
| FirstName: | TAMAR | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11260 OVERLAND AVE | ||||||||
| Address2: | #22A | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902305559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105593427 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10736 JEFFERSON BLVD | ||||||||
| Address2: | #172 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109360224 | ||||||||
| FaxNumber: | 3108232636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT26482 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 0PT264820 | 01 | CA | BLUE SHIELD PROVIDER # | OTHER |