Provider Demographics
NPI:1265920318
Name:BROWN, CONNIE SUE (DPT)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:SUE
Last Name:BROWN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:SUE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:755 XENIA AVE APT 45
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-5716
Mailing Address - Country:US
Mailing Address - Phone:442-284-1339
Mailing Address - Fax:
Practice Address - Street 1:1680 E ROSEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-746-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist