Provider Demographics
NPI:1790361723
Name:ITO, LORRAINE (PTA)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:ITO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PALM CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3100
Mailing Address - Country:US
Mailing Address - Phone:310-618-4295
Mailing Address - Fax:
Practice Address - Street 1:330 PALM CT
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3100
Practice Address - Country:US
Practice Address - Phone:310-618-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50782225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant