Provider Demographics
NPI:1649001033
Name:SHADLE, MALISSA KEI (DPT)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:KEI
Last Name:SHADLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E COLORADO ST STE 440
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1675
Mailing Address - Country:US
Mailing Address - Phone:833-477-6878
Mailing Address - Fax:
Practice Address - Street 1:425 E COLORADO ST STE 440
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1675
Practice Address - Country:US
Practice Address - Phone:833-477-6878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist