Provider Demographics
NPI:1669036992
Name:CONSTABLE, MARIANA THERESE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:THERESE
Last Name:CONSTABLE
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 ECHO CT APT D
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6642
Mailing Address - Country:US
Mailing Address - Phone:267-424-3099
Mailing Address - Fax:
Practice Address - Street 1:1415 RIDGEBACK RD STE 2
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6983
Practice Address - Country:US
Practice Address - Phone:757-650-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19528225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2674243099Medicaid