Provider Demographics
NPI:1902543002
Name:CONCHA, AILEEN (PT)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:
Last Name:CONCHA
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 1:10132 CAPETOWN LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7255
Mailing Address - Country:US
Mailing Address - Phone:209-598-3637
Mailing Address - Fax:
Practice Address - Street 1:10132 CAPETOWN LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7255
Practice Address - Country:US
Practice Address - Phone:209-598-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist