Provider Demographics
NPI:1891902649
Name:WORTHAM, DANIELLE ELISE (PT)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:ELISE
Last Name:WORTHAM
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 1:19024 MIRANDA ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1231
Mailing Address - Country:US
Mailing Address - Phone:310-503-7618
Mailing Address - Fax:818-757-7403
Practice Address - Street 1:19024 MIRANDA ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1231
Practice Address - Country:US
Practice Address - Phone:310-503-7618
Practice Address - Fax:818-757-7403
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT23754Medicare ID - Type UnspecifiedMEDICARE LEGACY NUMBER