Provider Demographics
NPI:1457854101
Name:DEL MAR, LISETTE SANTOS (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:SANTOS
Last Name:DEL MAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:LISETTE
Other - Middle Name:FARRALES
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:23426 MEHDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5222
Mailing Address - Country:US
Mailing Address - Phone:310-291-7599
Mailing Address - Fax:
Practice Address - Street 1:3820 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3625
Practice Address - Country:US
Practice Address - Phone:310-632-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist