Healthcare Provider Details

I. General information

NPI: 1689038432
Provider Name (Legal Business Name): DONNA PERSIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 GATEWAY BLVD N
CHESTERTON IN
46304-9658
US

IV. Provider business mailing address

8259 WICKER AVE
SAINT JOHN IN
46373-8878
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-1444
  • Fax: 219-926-6926
Mailing address:
  • Phone: 219-365-6560
  • Fax: 219-365-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002153A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: