Provider Demographics
NPI:1386804995
Name:BERMUDO, ERICA MESITAS (PT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MESITAS
Last Name:BERMUDO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:BERMUDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:255 CHANNING WAY APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2655
Mailing Address - Country:US
Mailing Address - Phone:415-686-2718
Mailing Address - Fax:
Practice Address - Street 1:100 THORNDALE DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4501
Practice Address - Country:US
Practice Address - Phone:415-891-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 28429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist