Provider Demographics
NPI:1598159527
Name:MASSUCCI, RODELYN
Entity Type:Individual
Prefix:
First Name:RODELYN
Middle Name:
Last Name:MASSUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47647 CALEO BAY DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8854
Mailing Address - Country:US
Mailing Address - Phone:760-771-9054
Mailing Address - Fax:760-771-9057
Practice Address - Street 1:47647 CALEO BAY DR
Practice Address - Street 2:SUITE 130
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8854
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:760-771-9057
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant