Provider Demographics
NPI:1346297967
Name:CONSOLACION, AGNES BUSTAMANTE (PT, CHT)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:BUSTAMANTE
Last Name:CONSOLACION
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5461
Mailing Address - Country:US
Mailing Address - Phone:510-769-7407
Mailing Address - Fax:415-447-3868
Practice Address - Street 1:1700 CALIFORNIA ST
Practice Address - Street 2:SUITE 450
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4586
Practice Address - Country:US
Practice Address - Phone:415-359-1444
Practice Address - Fax:415-447-3868
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist