Provider Demographics
NPI:1093304651
Name:VISSER, DANIELLE RENEE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:RENEE
Last Name:VISSER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:12460 N RANCHO VISTOSO BLVD STE 140
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-1989
Practice Address - Country:US
Practice Address - Phone:520-615-6573
Practice Address - Fax:520-575-7014
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019856225100000X
VA2305214876225100000X
AZLPT33211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501019856OtherSTATE LICENSE