Provider Demographics
NPI:1659480788
Name:MODERAU, STELLA (PTA)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:MODERAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 J AVE
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7521
Mailing Address - Country:US
Mailing Address - Phone:619-697-0018
Mailing Address - Fax:619-697-0051
Practice Address - Street 1:8090 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2105
Practice Address - Country:US
Practice Address - Phone:619-697-3093
Practice Address - Fax:619-697-3135
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT1210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant