Provider Demographics
NPI:1275893463
Name:TISDALE, CYNTHIA LEIGH (PTA)
Entity Type:Individual
Prefix:MISS
First Name:CYNTHIA
Middle Name:LEIGH
Last Name:TISDALE
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 1:605 SUNSET BLVD W # A
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-3614
Mailing Address - Country:US
Mailing Address - Phone:334-300-4223
Mailing Address - Fax:
Practice Address - Street 1:605 SUNSET BLVD W # A
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3614
Practice Address - Country:US
Practice Address - Phone:334-300-4223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant