Provider Demographics
NPI:1891401766
Name:DEUTZ, SUPHADA
Entity Type:Individual
Prefix:
First Name:SUPHADA
Middle Name:
Last Name:DEUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3344
Mailing Address - Country:US
Mailing Address - Phone:323-214-9025
Mailing Address - Fax:
Practice Address - Street 1:815 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3344
Practice Address - Country:US
Practice Address - Phone:323-214-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87537225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist