Provider Demographics
NPI:1720359995
Name:MASUDA, KELLIE (PT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MASUDA
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 1:7113 OSAGE RIVER CT
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 S ANAHEIM HILLS RD
Practice Address - Street 2:SUITE 106
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4780
Practice Address - Country:US
Practice Address - Phone:714-685-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist