Provider Demographics
NPI:1285843870
Name:JOSEPHSON, SHERYL GWEN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHERYL
Middle Name:GWEN
Last Name:JOSEPHSON
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 1:3016 OAK HAMMOCK DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6201
Mailing Address - Country:US
Mailing Address - Phone:386-761-8004
Mailing Address - Fax:
Practice Address - Street 1:900 LPGA BLVD
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-3113
Practice Address - Country:US
Practice Address - Phone:386-226-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 17631225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant