Provider Demographics
NPI:1205854841
Name:CONSBRUCK, SANDRA L (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:CONSBRUCK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4666 EVERHART DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1108
Mailing Address - Country:US
Mailing Address - Phone:330-896-7039
Mailing Address - Fax:330-665-1830
Practice Address - Street 1:3975 EMBASSY PKWY
Practice Address - Street 2:STE 103
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44720-1763
Practice Address - Country:US
Practice Address - Phone:330-668-4080
Practice Address - Fax:330-665-1830
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT06672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2289983Medicaid
S86819Medicare UPIN
OH2289983Medicaid