Provider Demographics
NPI:1508156415
Name:CHANG, CONNIE (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:IDETA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:555 W HACIENDA AVE
Mailing Address - Street 2:#105
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6546
Mailing Address - Country:US
Mailing Address - Phone:408-466-4951
Mailing Address - Fax:
Practice Address - Street 1:555 W HACIENDA AVE
Practice Address - Street 2:#105
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6546
Practice Address - Country:US
Practice Address - Phone:408-466-4951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA280172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic