Provider Demographics
NPI:1538790472
Name:SAN JOSE, CRESSIDA RIVADELO
Entity type:Individual
Prefix:
First Name:CRESSIDA
Middle Name:RIVADELO
Last Name:SAN JOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18230 ROLLING MEADOW WAY # 26
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1766
Mailing Address - Country:US
Mailing Address - Phone:301-978-1865
Mailing Address - Fax:
Practice Address - Street 1:18230 ROLLING MEADOW WAY # 26
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1766
Practice Address - Country:US
Practice Address - Phone:301-978-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty