Provider Demographics
NPI:1164602124
Name:DE LA O, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:DE LA O
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32261 CAMINO CAPISTRANO
Mailing Address - Street 2:SUITE D101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3746
Mailing Address - Country:US
Mailing Address - Phone:949-429-2155
Mailing Address - Fax:949-429-2151
Practice Address - Street 1:32261 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE D101
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3746
Practice Address - Country:US
Practice Address - Phone:949-429-2155
Practice Address - Fax:949-429-2151
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT322332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic