Provider Demographics
NPI:1720622400
Name:CHAN, CONNIE (DPT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 W ARMITAGE AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6318
Practice Address - Country:US
Practice Address - Phone:773-394-0796
Practice Address - Fax:773-394-3342
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297517225100000X
IL070-026568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist