Provider Demographics
NPI:1528389269
Name:TENISSON, ADRIA GOPPELT (PT, MPT)
Entity Type:Individual
Prefix:
First Name:ADRIA
Middle Name:GOPPELT
Last Name:TENISSON
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 RALSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7844
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:3525 LOMA VISTA RD STE C
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3165
Practice Address - Country:US
Practice Address - Phone:805-652-6955
Practice Address - Fax:805-652-6959
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22190225100000X
CAPT221902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT22190OtherPT LICENSE
CAPT22190OtherPT LICENSE