Provider Demographics
NPI:1225060700
Name:KHEBREH, DIANNE (PTA)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:KHEBREH
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 1:1436 12TH ST APT E
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6156
Mailing Address - Country:US
Mailing Address - Phone:310-643-9016
Mailing Address - Fax:310-536-0177
Practice Address - Street 1:2250 PARK PL
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4908
Practice Address - Country:US
Practice Address - Phone:310-643-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT1827225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT1827Medicare ID - Type UnspecifiedPTA