Provider Demographics
NPI:1417016379
Name:CHETELAT, SANDRA THOMSPON (PT)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:THOMSPON
Last Name:CHETELAT
Suffix:
Gender:F
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:PO BOX 963
Mailing Address - Street 2:
Mailing Address - City:SKYFOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92385-0963
Mailing Address - Country:US
Mailing Address - Phone:909-337-2521
Mailing Address - Fax:
Practice Address - Street 1:26571 ST. HWY 18
Practice Address - Street 2:SUITE B
Practice Address - City:RIMFOREST
Practice Address - State:CA
Practice Address - Zip Code:92378-0010
Practice Address - Country:US
Practice Address - Phone:909-337-4192
Practice Address - Fax:909-336-1982
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 8591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist