Provider Demographics
NPI:1538669239
Name:KERBAWY, MIRANDA JO (PT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JO
Last Name:KERBAWY
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 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3814
Mailing Address - Country:US
Mailing Address - Phone:310-648-3167
Mailing Address - Fax:310-648-3175
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3814
Practice Address - Country:US
Practice Address - Phone:310-648-3167
Practice Address - Fax:310-648-3175
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA294488OtherCA