Provider Demographics
NPI:1386748309
Name:CHABAN, CHARISSA LEE (MPT)
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:LEE
Last Name:CHABAN
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 1:2301 CAMINO RAMON STE 160
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-2031
Mailing Address - Country:US
Mailing Address - Phone:925-355-1900
Mailing Address - Fax:925-355-1903
Practice Address - Street 1:2301 CAMINO RAMON STE 160
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-2031
Practice Address - Country:US
Practice Address - Phone:925-355-1900
Practice Address - Fax:925-355-1903
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2446225100000X
CA33494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI560666Medicaid
HI560666Medicaid