Provider Demographics
NPI:1639346794
Name:MADAMBA, ALTHAEA GRACIA SOTELO (PT)
Entity Type:Individual
Prefix:MISS
First Name:ALTHAEA GRACIA
Middle Name:SOTELO
Last Name:MADAMBA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6408 CANNING PL
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4266
Mailing Address - Country:US
Mailing Address - Phone:919-453-0793
Mailing Address - Fax:
Practice Address - Street 1:6408 CANNING PL
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4266
Practice Address - Country:US
Practice Address - Phone:919-453-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist