Provider Demographics
NPI:1295750792
Name:LOCKE, THERESA (PT)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:LOCKE
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:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:ALTAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95221-0637
Mailing Address - Country:US
Mailing Address - Phone:209-736-0956
Mailing Address - Fax:209-736-0958
Practice Address - Street 1:571 STANISLAUS ST
Practice Address - Street 2:SUITE F
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95221-0637
Practice Address - Country:US
Practice Address - Phone:209-736-0956
Practice Address - Fax:209-736-0958
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT132160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18166ZMedicare ID - Type UnspecifiedPHYSICAL THERAPIST