Provider Demographics
NPI:1568673176
Name:WICHMANN, CLARA (PTA, BS)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:WICHMANN
Suffix:
Gender:F
Credentials:PTA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4239 CLEVELAND AVE UNIT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 LANDIS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2628
Practice Address - Country:US
Practice Address - Phone:619-498-8450
Practice Address - Fax:619-498-8453
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 5522225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty