Provider Demographics
NPI:1114393881
Name:WELCH, ILAH CAVANAUGH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ILAH
Middle Name:CAVANAUGH
Last Name:WELCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ILAH
Other - Middle Name:MARIE
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:739 1/2 D AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2125
Mailing Address - Country:US
Mailing Address - Phone:858-722-6749
Mailing Address - Fax:844-231-8868
Practice Address - Street 1:722 GENEVIEVE ST STE S
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2061
Practice Address - Country:US
Practice Address - Phone:858-848-6639
Practice Address - Fax:844-231-8868
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 42857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist