Provider Demographics
NPI:1689970931
Name:AVILA, ROSSANA (DPT)
Entity Type:Individual
Prefix:
First Name:ROSSANA
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 MOORPARK ST
Mailing Address - Street 2:SUITE 57
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:650-455-0605
Mailing Address - Fax:
Practice Address - Street 1:12526 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607
Practice Address - Country:US
Practice Address - Phone:818-985-2559
Practice Address - Fax:818-985-4459
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2018-04-20
Deactivation Date:2017-04-18
Deactivation Code:
Reactivation Date:2018-04-20
Provider Licenses
StateLicense IDTaxonomies
CAPT 37451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist