Provider Demographics
NPI:1225008386
Name:SANSONE, MARK (RPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SANSONE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CLEMSFORD SQ
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6787
Mailing Address - Country:US
Mailing Address - Phone:916-983-4713
Mailing Address - Fax:
Practice Address - Street 1:3084 CEDAR RAVINE RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5617
Practice Address - Country:US
Practice Address - Phone:530-621-2773
Practice Address - Fax:530-621-3202
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 13745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist