Provider Demographics
NPI:1033406343
Name:PEDRENA DE BODA, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PEDRENA DE BODA
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 1:235 N KENWOOD ST
Mailing Address - Street 2:APT. A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4288
Mailing Address - Country:US
Mailing Address - Phone:626-272-9738
Mailing Address - Fax:
Practice Address - Street 1:235 N KENWOOD ST
Practice Address - Street 2:APT. A
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4288
Practice Address - Country:US
Practice Address - Phone:626-272-9738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist