Provider Demographics
NPI:1710368113
Name:BALTAZAR, MICHELLE NOMBRE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:NOMBRE
Last Name:BALTAZAR
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 1:2386 SEACREST CT
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-2792
Mailing Address - Country:US
Mailing Address - Phone:510-712-0066
Mailing Address - Fax:
Practice Address - Street 1:2450 WASHINGTON AVE STE 295
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5998
Practice Address - Country:US
Practice Address - Phone:510-577-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist