1215433883 NPI number — SARA MARTHA STUTZ PHYSICAL THERAPIST

Table of content: SARA MARTHA STUTZ PHYSICAL THERAPIST (NPI 1215433883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215433883 NPI number — SARA MARTHA STUTZ PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUTZ
Provider First Name:
SARA
Provider Middle Name:
MARTHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215433883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1569 SOLANO AVE # 525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94707-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-375-5420
Provider Business Mailing Address Fax Number:
510-280-2556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
752 ENSENADA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94707-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-375-5420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  PT18410 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT18410 . This is a "PHYSICAL THERAPY BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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