Provider Demographics
NPI:1992027015
Name:SHRIVASTAVA, JOSHUA (MA, PTA, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:
Last Name:SHRIVASTAVA
Suffix:
Gender:M
Credentials:MA, PTA, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25512 GLORIOSA DR
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4644
Mailing Address - Country:US
Mailing Address - Phone:818-624-6162
Mailing Address - Fax:
Practice Address - Street 1:25512 GLORIOSA DR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4644
Practice Address - Country:US
Practice Address - Phone:818-624-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CAAT 10372225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant