Provider Demographics
NPI:1134535750
Name:WELLNESS INTERPROFESSIONAL PHYSICAL THERAPY CORPORATION, PC
Entity type:Organization
Organization Name:WELLNESS INTERPROFESSIONAL PHYSICAL THERAPY CORPORATION, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:JOSEPHINE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:323-730-1205
Mailing Address - Street 1:3501 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3237
Mailing Address - Country:US
Mailing Address - Phone:323-730-1205
Mailing Address - Fax:213-221-4778
Practice Address - Street 1:3501 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-3237
Practice Address - Country:US
Practice Address - Phone:323-730-1205
Practice Address - Fax:213-221-4778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53973106H00000X
CA874292084N0402X
CA631621223G0001X
CA80856106H00000X
CA22533364SA2200X
CA142802251N0400X, 261QM1300X
CA403792251P0200X
CA155872251G0304X
CA444501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922194175OtherNPI
CA1457570863OtherNPI 1457570863