Provider Demographics
NPI:1114071990
Name:BACCIOCCO, BRET J
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:J
Last Name:BACCIOCCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 VAN NUYS BLVD STE 314
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1852
Mailing Address - Country:US
Mailing Address - Phone:818-783-2396
Mailing Address - Fax:818-783-2467
Practice Address - Street 1:5000 VAN NUYS BLVD STE 314
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1852
Practice Address - Country:US
Practice Address - Phone:818-783-2396
Practice Address - Fax:818-783-2467
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT4252225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT4252OtherCA LICENCE