Provider Demographics
NPI:1093299588
Name:SANDBERG, MYKENZIE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:MYKENZIE
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:MYKENZIE
Other - Middle Name:
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1755 WITTINGTON PL STE 175
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-1905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1905
Practice Address - Country:US
Practice Address - Phone:214-442-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13613-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist