Provider Demographics
NPI:1548638703
Name:WEIDERMAN-TYRRELL, STARLIGHT (PT)
Entity type:Individual
Prefix:
First Name:STARLIGHT
Middle Name:
Last Name:WEIDERMAN-TYRRELL
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 1:3980 LAGO DI GRATA CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-8601
Mailing Address - Country:US
Mailing Address - Phone:619-990-0543
Mailing Address - Fax:
Practice Address - Street 1:3772 MISSION AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1453
Practice Address - Country:US
Practice Address - Phone:760-630-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist