Provider Demographics
NPI:1629257340
Name:HALLGREN, BRIANA (PT)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:HALLGREN
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 1:4250 PARK NEWPORT
Mailing Address - Street 2:APT 309
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-6066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2777 BRISTOL ST
Practice Address - Street 2:SUITE C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5997
Practice Address - Country:US
Practice Address - Phone:714-668-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17215BMedicare PIN
CACB211310Medicare PIN