Provider Demographics
NPI:1124871629
Name:VERISSIMO, TAYLOR (PT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:VERISSIMO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PALM AVE STE 126
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1246
Mailing Address - Country:US
Mailing Address - Phone:209-552-1181
Mailing Address - Fax:
Practice Address - Street 1:600 PALM AVE STE 126
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1246
Practice Address - Country:US
Practice Address - Phone:209-552-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist