Provider Demographics
NPI:1083188502
Name:CARUSO, GENNY (PTA)
Entity Type:Individual
Prefix:
First Name:GENNY
Middle Name:
Last Name:CARUSO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 WINONA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3341
Mailing Address - Country:US
Mailing Address - Phone:203-687-9383
Mailing Address - Fax:
Practice Address - Street 1:8344 CLAIREMONT MESA BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1327
Practice Address - Country:US
Practice Address - Phone:858-565-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant