Healthcare Provider Details

I. General information

NPI: 1063783108
Provider Name (Legal Business Name): SANDRA MITCHELL ROBERTSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA KAYE MITCHELL

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 WINDMILL ST
WALNUT COVE NC
27052-7706
US

IV. Provider business mailing address

511 WINDMILL ST
WALNUT COVE NC
27052-7706
US

V. Phone/Fax

Practice location:
  • Phone: 336-591-7357
  • Fax:
Mailing address:
  • Phone: 336-591-7357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2520
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: