Provider Demographics
NPI:1215252598
Name:MOTAMED, SHALA (PT)
Entity type:Individual
Prefix:
First Name:SHALA
Middle Name:
Last Name:MOTAMED
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 1:20969 VENTURA BLVD
Mailing Address - Street 2:23
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2305
Mailing Address - Country:US
Mailing Address - Phone:818-992-5252
Mailing Address - Fax:818-992-5292
Practice Address - Street 1:20969 VENTURA BLVD
Practice Address - Street 2:23
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2305
Practice Address - Country:US
Practice Address - Phone:818-992-5252
Practice Address - Fax:818-992-5292
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14153208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT14153OtherMEDICAL LICENSE