Provider Demographics
NPI:1659745651
Name:DE MARIA, CONNIE JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JEAN
Last Name:DE MARIA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 NW MARKET ST
Mailing Address - Street 2:STE 235
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4137
Mailing Address - Country:US
Mailing Address - Phone:206-861-4653
Mailing Address - Fax:
Practice Address - Street 1:116 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5360
Practice Address - Country:US
Practice Address - Phone:206-254-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160039700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP160039700OtherWASHINGTON STATE DEPARTMENT OF HEALTH PHYSICAL THERAPIST ASSISTANT