Provider Demographics
NPI:1255065223
Name:CONSTABLE, BREEANNA SUE (PTA)
Entity type:Individual
Prefix:
First Name:BREEANNA
Middle Name:SUE
Last Name:CONSTABLE
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 1:39815 ALTA MURRIETA DR STE C1
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5405
Mailing Address - Country:US
Mailing Address - Phone:951-304-7673
Mailing Address - Fax:
Practice Address - Street 1:39815 ALTA MURRIETA DR
Practice Address - Street 2:SUITE C-1
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-5405
Practice Address - Country:US
Practice Address - Phone:951-304-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5058225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant