=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235663162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA LORRAINE SCALESE PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2017
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 VALLEY STREET BRIAN CENTER HEALTH AND REHABILITATION
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-0517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 VALLEY STREET BRIAN CENTER HEALTH AND REHABILITATION
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-0517
-----------------------------------------------------
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 | A3122
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------