Healthcare Provider Details

I. General information

NPI: 1104821172
Provider Name (Legal Business Name): SANDRA LOUISE RADER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 STATE HIGHWAY 94
BLAIRSTOWN NJ
07825
US

IV. Provider business mailing address

421 S BEST AVE
WALNUTPORT PA
18088-1217
US

V. Phone/Fax

Practice location:
  • Phone: 908-362-6172
  • Fax: 908-362-6406
Mailing address:
  • Phone: 610-760-1520
  • Fax: 610-760-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015016
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00420600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: