Provider Demographics
NPI:1689272148
Name:LIEU, JONATHAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LIEU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10290 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-1410
Mailing Address - Country:US
Mailing Address - Phone:714-383-7355
Mailing Address - Fax:
Practice Address - Street 1:30025 ALICIA PKWY STE G-262
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2090
Practice Address - Country:US
Practice Address - Phone:714-281-0169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT299116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist