Provider Demographics
NPI:1497163430
Name:BURGESS, LORI (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BURGESS
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 1:1165 BRENNER RD
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6141
Mailing Address - Country:US
Mailing Address - Phone:918-224-0600
Mailing Address - Fax:
Practice Address - Street 1:1165 BRENNER RD
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6141
Practice Address - Country:US
Practice Address - Phone:918-224-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2242225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant