Provider Demographics
NPI:1386961779
Name:BLAGOJEVICH, DIANE LISABETH (PT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:LISABETH
Last Name:BLAGOJEVICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22029 MARJORIE AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-6938
Mailing Address - Country:US
Mailing Address - Phone:310-251-5996
Mailing Address - Fax:310-540-8237
Practice Address - Street 1:510 N PROSPECT AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3028
Practice Address - Country:US
Practice Address - Phone:310-372-4646
Practice Address - Fax:310-798-4667
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist