Provider Demographics
NPI:1407408503
Name:GUILLAUME, SALLY (PTA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GUILLAUME
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 1:449 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3722
Mailing Address - Country:US
Mailing Address - Phone:570-320-7458
Mailing Address - Fax:
Practice Address - Street 1:449 RIVER AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3722
Practice Address - Country:US
Practice Address - Phone:570-320-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI0039225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant