Provider Demographics
NPI:1295710382
Name:CORDES, CARMEN MARISSA (PT)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARISSA
Last Name:CORDES
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 1:3801 S HARBOR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7901
Mailing Address - Country:US
Mailing Address - Phone:714-665-8888
Mailing Address - Fax:714-751-9999
Practice Address - Street 1:3801 S HARBOR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7901
Practice Address - Country:US
Practice Address - Phone:714-665-8888
Practice Address - Fax:714-751-9999
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 12558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT12558AMedicare ID - Type Unspecified