Provider Demographics
NPI:1265400089
Name:NACHOUM, ILANA MAZAL (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:ILANA
Middle Name:MAZAL
Last Name:NACHOUM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2134
Mailing Address - Country:US
Mailing Address - Phone:415-922-7223
Mailing Address - Fax:
Practice Address - Street 1:9 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2195
Practice Address - Country:US
Practice Address - Phone:415-922-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist