Healthcare Provider Details

I. General information

NPI: 1679723407
Provider Name (Legal Business Name): AUDREY LAMAR OWENS MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S SAN MATEO DR
SAN MATEO CA
94401-3805
US

IV. Provider business mailing address

18 FAIRMOUNT ST
SAN FRANCISCO CA
94131-2768
US

V. Phone/Fax

Practice location:
  • Phone: 650-696-4012
  • Fax:
Mailing address:
  • Phone: 415-225-2406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number28998-PT
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: