Provider Demographics
NPI:1629583729
Name:LAO, STAPHANY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STAPHANY
Middle Name:
Last Name:LAO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 PATRICIA ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2606
Mailing Address - Country:US
Mailing Address - Phone:626-678-6826
Mailing Address - Fax:
Practice Address - Street 1:16305 SAND CANYON AVE STE 210
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3783
Practice Address - Country:US
Practice Address - Phone:949-752-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist