Basic Information
Provider Information
NPI: 1003143041
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TESORIO
FirstName: CLYTIC MARIE
MiddleName: VILLAS
NamePrefix: MS.
NameSuffix:  
Credential: PT-DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 12411 SLAUSON AVE.
Address2: UNIT H
City: WHITTIER
State: CA
PostalCode: 90606
CountryCode: US
TelephoneNumber: 5626935449
FaxNumber: 5626935469
Practice Location
Address1: 12411 SLAUSON AVE.
Address2: UNIT H
City: WHITTIER
State: CA
PostalCode: 90606
CountryCode: US
TelephoneNumber: 5626935449
FaxNumber: 5626935469
Other Information
ProviderEnumerationDate: 11/12/2009
LastUpdateDate: 11/12/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
2251P0200X  N Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics

No ID Information.


Home