Provider Demographics
NPI:1215911235
Name:WISWALL, DANIELLE THEONE (MPT)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:THEONE
Last Name:WISWALL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 VULCAN DR
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-733-7500
Mailing Address - Fax:805-733-7510
Practice Address - Street 1:177 VULCAN DR
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-733-7500
Practice Address - Fax:805-733-7510
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0261360OtherSBHI
CAPT0261360OtherMEDI-CAL
CAPT26136Medicare ID - Type Unspecified