Provider Demographics
NPI:1487825865
Name:SUYAMA, STACY (DPT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SUYAMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 APOLLO ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4723
Mailing Address - Country:US
Mailing Address - Phone:310-606-5664
Mailing Address - Fax:
Practice Address - Street 1:840 APOLLO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4723
Practice Address - Country:US
Practice Address - Phone:310-606-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist