Provider Demographics
NPI:1477008316
Name:DELEON, DEANNA CONCHITA (PTA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:CONCHITA
Last Name:DELEON
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 1:501 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-3409
Mailing Address - Country:US
Mailing Address - Phone:813-215-6234
Mailing Address - Fax:
Practice Address - Street 1:3248 LITHIA PINECREST RD STE 102
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5682
Practice Address - Country:US
Practice Address - Phone:813-662-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant