Provider Demographics
NPI:1114044062
Name:MAYO, COLEEN KAY (PT)
Entity Type:Individual
Prefix:MS
First Name:COLEEN
Middle Name:KAY
Last Name:MAYO
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 1:9381 FIRESIDE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5903
Mailing Address - Country:US
Mailing Address - Phone:714-963-7965
Mailing Address - Fax:
Practice Address - Street 1:17456 BEACH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5913
Practice Address - Country:US
Practice Address - Phone:714-841-2688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist