Provider Demographics
NPI:1871065938
Name:AGULTO, TANYA MARIE OLIVEROS (RPT)
Entity type:Individual
Prefix:
First Name:TANYA MARIE
Middle Name:OLIVEROS
Last Name:AGULTO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 JUSTICIA LN
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-6099
Mailing Address - Country:US
Mailing Address - Phone:805-368-5477
Mailing Address - Fax:
Practice Address - Street 1:5445 EVERGLADES ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6523
Practice Address - Country:US
Practice Address - Phone:805-642-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist