Provider Demographics
NPI:1306929484
Name:MAILLARD, RENE ANDRE (PT)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:ANDRE
Last Name:MAILLARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 E NAPA ST
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-3834
Mailing Address - Country:US
Mailing Address - Phone:707-721-6405
Mailing Address - Fax:
Practice Address - Street 1:3421 VILLA LN STE A
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3056
Practice Address - Country:US
Practice Address - Phone:707-257-4089
Practice Address - Fax:707-257-4188
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00160372OtherRAIL ROAD MEDICARE
CA0PT246740OtherBLUE SHIELD
CAP00160372OtherRAIL ROAD MEDICARE