Provider Demographics
NPI:1700522125
Name:DWYER, ADDISON (PTA)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:DWYER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 BELGIUM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-9413
Mailing Address - Country:US
Mailing Address - Phone:530-966-2330
Mailing Address - Fax:
Practice Address - Street 1:240 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-2216
Practice Address - Country:US
Practice Address - Phone:530-292-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51867225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant