Provider Demographics
NPI:1083155931
Name:LLOSA PERALTA, SANDRA ARLENNE (PTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ARLENNE
Last Name:LLOSA PERALTA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 NE 167TH ST
Mailing Address - Street 2:APT 205
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-5103
Mailing Address - Country:US
Mailing Address - Phone:305-922-9899
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7260
Practice Address - Country:US
Practice Address - Phone:954-735-3535
Practice Address - Fax:954-484-7000
Is Sole Proprietor?:No
Enumeration Date:2017-03-12
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27216225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant