Provider Demographics
NPI:1700867157
Name:SHOCKLEY, BETTINA KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:KATHLEEN
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19510 VENTURA BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2969
Mailing Address - Country:US
Mailing Address - Phone:818-996-1725
Mailing Address - Fax:818-996-0210
Practice Address - Street 1:26357 MCBEAN PKWY
Practice Address - Street 2:STE 220
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355
Practice Address - Country:US
Practice Address - Phone:661-254-0077
Practice Address - Fax:661-254-2788
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT23022BMedicare ID - Type Unspecified
CAWPT23022AMedicare ID - Type Unspecified