Provider Demographics
NPI:1669421087
Name:FAHEY, LAURA (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8410 DERFER DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5462
Mailing Address - Country:US
Mailing Address - Phone:315-345-8741
Mailing Address - Fax:
Practice Address - Street 1:3111 SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-1357
Practice Address - Country:US
Practice Address - Phone:626-443-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34688225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist