Provider Demographics
NPI:1134289259
Name:LACAILLADE, IRENE VAUGHAN (DPT)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:VAUGHAN
Last Name:LACAILLADE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:IRENE
Other - Middle Name:VAUGHAN
Other - Last Name:SCHMID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:1158 26TH STREET
Mailing Address - Street 2:# 320
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-453-6166
Mailing Address - Fax:310-453-6154
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:# 311
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-453-6166
Practice Address - Fax:310-453-6154
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33131OtherLIC CA NUMBER
CA33131OtherLIC CA NUMBER