Provider Demographics
NPI:1962866251
Name:GABRIEL, LYRA KATRINA (PT)
Entity Type:Individual
Prefix:
First Name:LYRA KATRINA
Middle Name:
Last Name:GABRIEL
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 1:1213 CATHEDRAL OAKS RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2649
Mailing Address - Country:US
Mailing Address - Phone:619-888-9973
Mailing Address - Fax:
Practice Address - Street 1:1213 CATHEDRAL OAKS RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-2649
Practice Address - Country:US
Practice Address - Phone:619-888-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist