Provider Demographics
NPI:1194113183
Name:GAJARDO, SHEILA
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:GAJARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N LOS ROBLES AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2150
Mailing Address - Country:US
Mailing Address - Phone:323-610-1927
Mailing Address - Fax:
Practice Address - Street 1:1575 N LOS ROBLES AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2150
Practice Address - Country:US
Practice Address - Phone:323-610-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40720225100000X
WAPT60091106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist