Provider Demographics
NPI:1194876839
Name:CORYELL HIRST, IDA L (PT)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:L
Last Name:CORYELL HIRST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:LOUISE
Other - Last Name:HIRST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3908 VALLEY AVE.
Mailing Address - Street 2:STE. B
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566
Mailing Address - Country:US
Mailing Address - Phone:925-417-8005
Mailing Address - Fax:925-417-8881
Practice Address - Street 1:3908 VALLEY AVE
Practice Address - Street 2:STE. B
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-4872
Practice Address - Country:US
Practice Address - Phone:925-417-8005
Practice Address - Fax:925-417-8881
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT139040Medicare UPIN
CA943101918OtherTAX ID #