Provider Demographics
NPI:1699320689
Name:SISON, MARLO ACUESTA (PTA)
Entity type:Individual
Prefix:MR
First Name:MARLO
Middle Name:ACUESTA
Last Name:SISON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23310 MARIGOLD AVE UNIT 203
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2762
Mailing Address - Country:US
Mailing Address - Phone:424-772-8445
Mailing Address - Fax:
Practice Address - Street 1:20820 EARL ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4307
Practice Address - Country:US
Practice Address - Phone:310-371-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49744225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant