Provider Demographics
NPI:1245380229
Name:LOSSEV, GRACE REIKO
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:REIKO
Last Name:LOSSEV
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:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94576-0338
Mailing Address - Country:US
Mailing Address - Phone:707-968-7288
Mailing Address - Fax:
Practice Address - Street 1:20601 WEST PAOLI LANE
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:CA
Practice Address - Zip Code:95736
Practice Address - Country:US
Practice Address - Phone:530-422-7906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPT000074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 21838OtherCALIFORNIA PHYSICAL THERAPIST
GUPT000074OtherGUAM LICENSE