Provider Demographics
NPI:1740994524
Name:CORRALEJO, JULIE (PTA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:CORRALEJO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 LYNCH CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2342
Mailing Address - Country:US
Mailing Address - Phone:707-889-7478
Mailing Address - Fax:
Practice Address - Street 1:151 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2342
Practice Address - Country:US
Practice Address - Phone:707-889-7478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8445225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant