Provider Demographics
NPI:1851314272
Name:RODE, MAVIS (DPT)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:RODE
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 1:12425 BROOKLAKE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1807
Mailing Address - Country:US
Mailing Address - Phone:310-397-2740
Mailing Address - Fax:310-397-2740
Practice Address - Street 1:12425 BROOKLAKE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-1807
Practice Address - Country:US
Practice Address - Phone:310-397-2740
Practice Address - Fax:310-397-2740
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist