Provider Demographics
NPI:1538389648
Name:CHAN, BRENDA MOLINE (PT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:MOLINE
Last Name:CHAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JO
Other - Last Name:MOLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3500 LOMITA BLVD
Mailing Address - Street 2:SUITE M100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5021
Mailing Address - Country:US
Mailing Address - Phone:310-325-7404
Mailing Address - Fax:310-325-4971
Practice Address - Street 1:3500 LOMITA BLVD
Practice Address - Street 2:SUITE M100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5021
Practice Address - Country:US
Practice Address - Phone:310-325-7404
Practice Address - Fax:310-325-4971
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist