Provider Demographics
NPI:1063799898
Name:KOO, LIANNE K (DPT)
Entity type:Individual
Prefix:
First Name:LIANNE
Middle Name:K
Last Name:KOO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LIANNE
Other - Middle Name:K
Other - Last Name:NAKAZAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3814
Mailing Address - Country:US
Mailing Address - Phone:310-648-3167
Mailing Address - Fax:310-648-3175
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:310-648-3167
Practice Address - Fax:310-648-3175
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist