Provider Demographics
NPI:1447206651
Name:EZAKI, JULIE TERI (PTA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:TERI
Last Name:EZAKI
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 1:24171 PAVION
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2200
Mailing Address - Country:US
Mailing Address - Phone:949-707-2190
Mailing Address - Fax:
Practice Address - Street 1:200 W SANTA ANA BLVD
Practice Address - Street 2:#100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4134
Practice Address - Country:US
Practice Address - Phone:714-347-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 5059225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant