Provider Demographics
NPI:1376196295
Name:TADROSS, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:TADROSS
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 1:7921 PROFESSIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1901
Mailing Address - Country:US
Mailing Address - Phone:714-847-8751
Mailing Address - Fax:
Practice Address - Street 1:7921 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1901
Practice Address - Country:US
Practice Address - Phone:714-847-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA300177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician