Provider Demographics
NPI:1366707838
Name:FLACK, CHERL SONALI (PTA)
Entity type:Individual
Prefix:MS
First Name:CHERL
Middle Name:SONALI
Last Name:FLACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:CHERYL
Other - Middle Name:SONALI
Other - Last Name:BECKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:28463 COACHMAN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346
Mailing Address - Country:US
Mailing Address - Phone:909-425-0201
Mailing Address - Fax:
Practice Address - Street 1:9089 CLAREMONT AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92177
Practice Address - Country:US
Practice Address - Phone:180-078-7678
Practice Address - Fax:800-787-6762
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2799225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22520000XMedicare Oscar/Certification