Provider Demographics
NPI:1184016545
Name:DIFATTA, GEENA (DPT)
Entity Type:Individual
Prefix:
First Name:GEENA
Middle Name:
Last Name:DIFATTA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 SHASTA LN
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-4176
Mailing Address - Country:US
Mailing Address - Phone:805-296-1111
Mailing Address - Fax:
Practice Address - Street 1:455 HICKEY BLVD
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2629
Practice Address - Country:US
Practice Address - Phone:650-746-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist