Provider Demographics
NPI:1568093383
Name:LABEAUD, CONNIE MARIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:LABEAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3205
Mailing Address - Country:US
Mailing Address - Phone:909-792-0001
Mailing Address - Fax:909-792-0018
Practice Address - Street 1:415 ORANGE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3205
Practice Address - Country:US
Practice Address - Phone:909-792-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53083225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist