Provider Demographics
NPI:1346326345
Name:VAN DE MARK, SALLY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:VAN DE MARK
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:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742-0426
Mailing Address - Country:US
Mailing Address - Phone:845-794-0209
Mailing Address - Fax:845-794-0716
Practice Address - Street 1:14 HARRIS BUSHVILLE RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-794-0209
Practice Address - Fax:845-794-0716
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005767-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant