Provider Demographics
NPI:1639787732
Name:LU, XANDEE
Entity Type:Individual
Prefix:
First Name:XANDEE
Middle Name:
Last Name:LU
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 1:138 S ADAMS ST APT 5
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1008
Practice Address - Country:US
Practice Address - Phone:818-247-3395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10306225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10306OtherPTA