Provider Demographics
NPI:1780089052
Name:KOSTUKOVSKY, ALISA (PT, DPT)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:KOSTUKOVSKY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18110 BROMLEY ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1701
Mailing Address - Country:US
Mailing Address - Phone:818-383-9708
Mailing Address - Fax:
Practice Address - Street 1:18110 BROMLEY ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1701
Practice Address - Country:US
Practice Address - Phone:818-383-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41808225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist