Healthcare Provider Details

I. General information

NPI: 1669036992
Provider Name (Legal Business Name): MARIANA THERESE CONSTABLE MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 RIDGEBACK RD STE 2
CHULA VISTA CA
91910-6983
US

IV. Provider business mailing address

4313 ECHO CT APT D
LA MESA CA
91941-6642
US

V. Phone/Fax

Practice location:
  • Phone: 757-650-6636
  • Fax:
Mailing address:
  • Phone: 267-424-3099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number19528
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: