Provider Demographics
NPI:1144860743
Name:SHADRAVAN, ROESHAN (PHD DOMP MSC CST)
Entity type:Individual
Prefix:
First Name:ROESHAN
Middle Name:
Last Name:SHADRAVAN
Suffix:
Gender:F
Credentials:PHD DOMP MSC CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 N COAST HIGHWAY 101 #232126
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023
Mailing Address - Country:US
Mailing Address - Phone:760-212-1678
Mailing Address - Fax:
Practice Address - Street 1:1505 LOMAS SANTA FE DR
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2103
Practice Address - Country:US
Practice Address - Phone:760-212-1678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172M00000X
CA30079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist