Provider Demographics
NPI:1104466325
Name:EPISCOPE, EDELISA ROSE RUSTIA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MISS
First Name:EDELISA ROSE
Middle Name:RUSTIA
Last Name:EPISCOPE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
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Other - First Name:
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Mailing Address - Street 1:16344 VINTAGE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1317
Mailing Address - Country:US
Mailing Address - Phone:818-398-4569
Mailing Address - Fax:
Practice Address - Street 1:11441 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3143
Practice Address - Country:US
Practice Address - Phone:818-980-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22712012OtherKAISER PERMANENTE