Provider Demographics
NPI:1275067993
Name:RAGLAND, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RAGLAND
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 1:4220 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3511
Mailing Address - Country:US
Mailing Address - Phone:562-342-9994
Mailing Address - Fax:562-342-9484
Practice Address - Street 1:4220 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3511
Practice Address - Country:US
Practice Address - Phone:562-342-9994
Practice Address - Fax:562-342-9484
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48667225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTA48667OtherSTATE PTA LICENSE NUMBER