Provider Demographics
NPI:1154633923
Name:REY, MAURA SURIBA (PT)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:SURIBA
Last Name:REY
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 1:1224 E GLENOAKS BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2543
Mailing Address - Country:US
Mailing Address - Phone:818-571-2801
Mailing Address - Fax:
Practice Address - Street 1:2010 WILSHIRE BLVD STE 404
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3598
Practice Address - Country:US
Practice Address - Phone:213-353-0003
Practice Address - Fax:213-353-0004
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 27821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist