Provider Demographics
NPI:1275225153
Name:ISLAS, MONICA LISETTE (ATC)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LISETTE
Last Name:ISLAS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 BROADWAY ST APT 325
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2646
Mailing Address - Country:US
Mailing Address - Phone:209-675-1864
Mailing Address - Fax:
Practice Address - Street 1:6035 GIANT RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-2388
Practice Address - Country:US
Practice Address - Phone:209-675-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000367932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer