Provider Demographics
NPI:1619121068
Name:GEOFFROY, SURINA (PT)
Entity Type:Individual
Prefix:
First Name:SURINA
Middle Name:
Last Name:GEOFFROY
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:PO BOX 1354
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-1354
Mailing Address - Country:US
Mailing Address - Phone:562-424-4815
Mailing Address - Fax:
Practice Address - Street 1:2880 ATLANTIC AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1714
Practice Address - Country:US
Practice Address - Phone:562-424-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12219225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT12219OtherPHYSICAL THERAPIST LICENSE