Provider Demographics
NPI:1659460103
Name:POULSEN, RICHARD P (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
Last Name:POULSEN
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3662 KATELLA AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3124
Mailing Address - Country:US
Mailing Address - Phone:562-799-4494
Mailing Address - Fax:562-280-0304
Practice Address - Street 1:3662 KATELLA AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3124
Practice Address - Country:US
Practice Address - Phone:562-799-4494
Practice Address - Fax:562-280-0304
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT29339AMedicare ID - Type Unspecified