Provider Demographics
NPI:1659603108
Name:RYNEARSON, ELISSA R (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:ELISSA
Middle Name:R
Last Name:RYNEARSON
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 1:20911 CATAMARAN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5517
Mailing Address - Country:US
Mailing Address - Phone:714-595-9246
Mailing Address - Fax:
Practice Address - Street 1:15805 S BUDLONG AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4303
Practice Address - Country:US
Practice Address - Phone:310-327-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT350662251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics