Provider Demographics
NPI:1689905176
Name:OBILLO, CORAZON MANGLANLAN (PT)
Entity Type:Individual
Prefix:
First Name:CORAZON
Middle Name:MANGLANLAN
Last Name:OBILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CORAZON
Other - Middle Name:
Other - Last Name:OBILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1609 SE 92ND COURT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664
Mailing Address - Country:US
Mailing Address - Phone:360-917-8562
Mailing Address - Fax:
Practice Address - Street 1:1609 SE 92ND COURT
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-737-7527
Practice Address - Fax:360-694-8613
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6112225100000X
WA60113682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist