Healthcare Provider Details

I. General information

NPI: 1730308628
Provider Name (Legal Business Name): SANDRA LYNN HAUCK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9740 WYLAND CT
WINDERMERE FL
34786-5610
US

IV. Provider business mailing address

1002 S DILLARD ST SUITE 106
WINTER GARDEN FL
34787-3991
US

V. Phone/Fax

Practice location:
  • Phone: 407-876-0044
  • Fax: 407-905-8908
Mailing address:
  • Phone: 407-905-8908
  • Fax: 407-905-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 19258
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: