Provider Demographics
NPI:1093727794
Name:DETHLOFF, MELISSA DEANNE (MPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DEANNE
Last Name:DETHLOFF
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 KUEHNER DR
Mailing Address - Street 2:#115
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3900
Mailing Address - Country:US
Mailing Address - Phone:805-823-8200
Mailing Address - Fax:805-823-8208
Practice Address - Street 1:2315 KUEHNER DR
Practice Address - Street 2:#115
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-3900
Practice Address - Country:US
Practice Address - Phone:805-823-8200
Practice Address - Fax:805-823-8208
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist