Provider Demographics
NPI:1306908181
Name:PHELAN, TAMARA L (P T)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:PHELAN
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4904
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-0904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3215 N CALIFORNIA ST
Practice Address - Street 2:SUITE 4
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3433
Practice Address - Country:US
Practice Address - Phone:209-464-6016
Practice Address - Fax:209-464-6017
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist