Provider Demographics
NPI:1417905167
Name:IMRISEK, NATALIE A (MS PT)
Entity Type:Individual
Prefix:MS
First Name:NATALIE
Middle Name:A
Last Name:IMRISEK
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 WHITLEY AVE
Mailing Address - Street 2:#212
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028
Mailing Address - Country:US
Mailing Address - Phone:323-315-9717
Mailing Address - Fax:
Practice Address - Street 1:1837 WHITLEY AVE
Practice Address - Street 2:#212
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028
Practice Address - Country:US
Practice Address - Phone:323-315-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0267341225100000X
NY6226734225100000X
CA38172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300000687Medicare PIN
NYQ28H4Q49E1Medicare PIN