Provider Demographics
NPI:1477090181
Name:LY, KARISSA DAWN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:DAWN
Last Name:LY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KARISSA
Other - Middle Name:DAWN
Other - Last Name:IMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 ROLLING OAKS DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1088
Mailing Address - Country:US
Mailing Address - Phone:805-446-3141
Mailing Address - Fax:805-446-3140
Practice Address - Street 1:22122 SHERMAN WAY
Practice Address - Street 2:SUITE 106
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1140
Practice Address - Country:US
Practice Address - Phone:818-592-6030
Practice Address - Fax:818-592-6034
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist