Provider Demographics
NPI:1326670282
Name:CHACON, COURTNEY (PTA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CHACON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 MUIRWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2434
Mailing Address - Country:US
Mailing Address - Phone:530-301-9749
Mailing Address - Fax:
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR STE 275
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4653
Practice Address - Country:US
Practice Address - Phone:925-736-1305
Practice Address - Fax:925-736-7625
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50518208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty