=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134379977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA METTEN-MILES PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2008
-----------------------------------------------------
Last Update Date | 09/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 WINTER AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40204-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-291-8873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 WINTER AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40204-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-291-8873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA-A00483
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------