Provider Demographics
NPI:1629476262
Name:AMMAR, IRENE (CMT)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:AMMAR
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 ANTELOPE AVE APT 30
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5597
Mailing Address - Country:US
Mailing Address - Phone:707-480-1567
Mailing Address - Fax:
Practice Address - Street 1:1403 5TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3900
Practice Address - Country:US
Practice Address - Phone:707-480-1567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-14
Last Update Date:2014-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACMT #60412225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist