Provider Demographics
NPI:1376138362
Name:ARTZ, SALLY E (PTA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:E
Last Name:ARTZ
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 1:1313 PRATT ST
Mailing Address - Street 2:
Mailing Address - City:BARRY
Mailing Address - State:IL
Mailing Address - Zip Code:62312-1365
Mailing Address - Country:US
Mailing Address - Phone:217-335-2326
Mailing Address - Fax:
Practice Address - Street 1:1313 PRATT ST
Practice Address - Street 2:
Practice Address - City:BARRY
Practice Address - State:IL
Practice Address - Zip Code:62312-1365
Practice Address - Country:US
Practice Address - Phone:217-335-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004031225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160004031OtherPTA LICENSE