Provider Demographics
NPI:1255926473
Name:CONTRERAS, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:CONTRERAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23007 VISTA GRANDE WAY
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-4964
Mailing Address - Country:US
Mailing Address - Phone:702-279-7787
Mailing Address - Fax:
Practice Address - Street 1:22597 BARTON RD STE B
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5267
Practice Address - Country:US
Practice Address - Phone:909-264-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 2255A2300X
CAF51328992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF5132899OtherDRIVERS LICENSE