Healthcare Provider Details

I. General information

NPI: 1255487294
Provider Name (Legal Business Name): SALLY MARLENE STREET PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6504 E 129TH AVE
CROWN POINT IN
46307-9087
US

IV. Provider business mailing address

2906 W 77TH AVE
MERRILLVILLE IN
46410-4518
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-7654
  • Fax: 219-662-2136
Mailing address:
  • Phone: 219-769-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06000212A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: