Provider Demographics
NPI:1093032781
Name:PULICKAL, THERESA R (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:R
Last Name:PULICKAL
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 1:3920 RIVIERA DR
Mailing Address - Street 2:UNIT G
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5835
Mailing Address - Country:US
Mailing Address - Phone:773-771-8906
Mailing Address - Fax:
Practice Address - Street 1:7862 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-6712
Practice Address - Country:US
Practice Address - Phone:619-644-6452
Practice Address - Fax:619-466-7528
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist