Provider Demographics
NPI:1639846249
Name:CARLOS, MALYSSA ROBIN (MA)
Entity Type:Individual
Prefix:
First Name:MALYSSA
Middle Name:ROBIN
Last Name:CARLOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:410 S CLEMENTINE ST APT 207
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3855
Mailing Address - Country:US
Mailing Address - Phone:562-361-6884
Mailing Address - Fax:909-757-6400
Practice Address - Street 1:1235 INDIANA CT STE 107
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4540
Practice Address - Country:US
Practice Address - Phone:909-566-3358
Practice Address - Fax:909-757-6400
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2088491225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2088491Medicaid