Provider Demographics
NPI:1538201546
Name:SEBASTOPOL PHYSICAL THERAPY AND PILATES STUDIO
Entity type:Organization
Organization Name:SEBASTOPOL PHYSICAL THERAPY AND PILATES STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:DONOVAN
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-829-3282
Mailing Address - Street 1:100 PLEASANT HILL AVE N
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3104
Mailing Address - Country:US
Mailing Address - Phone:707-829-3282
Mailing Address - Fax:
Practice Address - Street 1:100 PLEASANT HILL AVE N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3104
Practice Address - Country:US
Practice Address - Phone:707-829-3282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07609ZOtherBLUE SHIELD PROVIDER NUMB
CAZZZ27518ZMedicare PIN