Provider Demographics
NPI:1699109116
Name:VASCONCELLOS, ALYSON RICHELE (DPT)
Entity type:Individual
Prefix:
First Name:ALYSON
Middle Name:RICHELE
Last Name:VASCONCELLOS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALYSON
Other - Middle Name:RICHELE
Other - Last Name:HOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2777 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:949-250-1112
Mailing Address - Fax:949-250-1401
Practice Address - Street 1:2777 BRISTOL ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:949-250-1401
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB204507Medicare UPIN