Provider Demographics
NPI:1366934648
Name:UNDERWOOD, CHAD D (PTA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:D
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 LARWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3512
Mailing Address - Country:US
Mailing Address - Phone:562-822-9680
Mailing Address - Fax:
Practice Address - Street 1:19531 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2902
Practice Address - Country:US
Practice Address - Phone:714-960-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10761225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant