Provider Demographics
NPI:1487268207
Name:CASANOVA SIWIUK TARASIUK, CAMILA PAULA (CMT)
Entity type:Individual
Prefix:
First Name:CAMILA PAULA
Middle Name:
Last Name:CASANOVA SIWIUK TARASIUK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 S DELAWARE ST UNIT 5427
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-6623
Mailing Address - Country:US
Mailing Address - Phone:650-283-6084
Mailing Address - Fax:
Practice Address - Street 1:537 MARIPOSA AVE APT 2
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-1728
Practice Address - Country:US
Practice Address - Phone:650-283-6084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76286225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist