Provider Demographics
NPI:1003170846
Name:YASUHARA, IZUMI (PT)
Entity Type:Individual
Prefix:
First Name:IZUMI
Middle Name:
Last Name:YASUHARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1295
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90294-1295
Mailing Address - Country:US
Mailing Address - Phone:888-859-0145
Mailing Address - Fax:888-858-1601
Practice Address - Street 1:6080 CENTER DR FL 6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-9205
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38963OtherCA STATE PT LIC