Basic Information
| Provider Information | |||||||||
| NPI: | 1538210893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEALE | ||||||||
| FirstName: | MARRIANNE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWPORT CENTER DR | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496441322 | ||||||||
| FaxNumber: | 9496440316 | ||||||||
| Practice Location | |||||||||
| Address1: | 36 MAUCHLY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497273315 | ||||||||
| FaxNumber: | 9497273624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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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 | PT 32143 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT 32143 | 01 | CA | PHYSICAL THERAPY LICENSE | OTHER | WPT32143A | 01 | CA | MEDICARE PTAN | OTHER |