Provider Demographics
NPI:1154569887
Name:CHAE, ALLY (MPT)
Entity type:Individual
Prefix:
First Name:ALLY
Middle Name:
Last Name:CHAE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-2660
Mailing Address - Country:US
Mailing Address - Phone:805-765-4773
Mailing Address - Fax:805-392-9975
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-2660
Practice Address - Country:US
Practice Address - Phone:805-765-4773
Practice Address - Fax:805-392-9975
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35256174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS81676Medicare UPIN