Provider Demographics
NPI:1588980759
Name:PAGANO, GRACIELA (PT)
Entity type:Individual
Prefix:MRS
First Name:GRACIELA
Middle Name:
Last Name:PAGANO
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 1:1037 AQUARIUS WAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1939
Mailing Address - Country:US
Mailing Address - Phone:510-388-3664
Mailing Address - Fax:
Practice Address - Street 1:4179 PIEDMONT AVE STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5187
Practice Address - Country:US
Practice Address - Phone:510-388-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24633225100000X, 2251X0800X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic