Provider Demographics
NPI:1720511579
Name:MUTH, MAUREEN (ATC)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MUTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-1429
Mailing Address - Country:US
Mailing Address - Phone:707-363-6007
Mailing Address - Fax:
Practice Address - Street 1:1254 GROVE WAY
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-1429
Practice Address - Country:US
Practice Address - Phone:707-363-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000265692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer