Provider Demographics
NPI:1053167049
Name:PETROSYAN, NELSON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:
Last Name:PETROSYAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 VERDUGO CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1535
Mailing Address - Country:US
Mailing Address - Phone:818-426-5616
Mailing Address - Fax:
Practice Address - Street 1:435 ARDEN AVE STE 340
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4017
Practice Address - Country:US
Practice Address - Phone:818-426-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT39694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist