Provider Demographics
NPI:1871807792
Name:MIRTAHERI, POURANDOKHT (PT)
Entity type:Individual
Prefix:
First Name:POURANDOKHT
Middle Name:
Last Name:MIRTAHERI
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 1:10535 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1807
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024
Mailing Address - Country:US
Mailing Address - Phone:310-475-0547
Mailing Address - Fax:310-475-0547
Practice Address - Street 1:10535 WILSHIRE BLVD.
Practice Address - Street 2:SUITE 1807
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004
Practice Address - Country:US
Practice Address - Phone:310-475-0547
Practice Address - Fax:310-475-0547
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist