Provider Demographics
NPI:1124203468
Name:HALVERSON, DANICA NOEL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DANICA
Middle Name:NOEL
Last Name:HALVERSON
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 1:712 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2524
Mailing Address - Country:US
Mailing Address - Phone:714-390-8607
Mailing Address - Fax:
Practice Address - Street 1:2951 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3912
Practice Address - Country:US
Practice Address - Phone:714-546-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-06
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 8467225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant