Provider Demographics
NPI:1487867867
Name:SAN AGUSTIN, CHERYL E (PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:E
Last Name:SAN AGUSTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TAHITI WAY APT 218
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 522
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-477-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 17102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist