Provider Demographics
NPI:1316437049
Name:JANELLE-HETO, THERESA (CAMTC #58614)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JANELLE-HETO
Suffix:
Gender:F
Credentials:CAMTC #58614
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:JANELLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NCBTMB
Mailing Address - Street 1:6243 ADOBE CIR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-5103
Mailing Address - Country:US
Mailing Address - Phone:603-345-4321
Mailing Address - Fax:
Practice Address - Street 1:23541 CALLE DE LA LOUISA STE B
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3605
Practice Address - Country:US
Practice Address - Phone:949-534-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist