Provider Demographics
NPI:1558682971
Name:SOUTHERLAND, ASHLEY PAGE (PTA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:PAGE
Last Name:SOUTHERLAND
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 1:1409 GENEVA CIR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-4780
Mailing Address - Country:US
Mailing Address - Phone:423-202-0574
Mailing Address - Fax:423-623-2924
Practice Address - Street 1:132 NEWPORT TOWNE CTR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-7360
Practice Address - Country:US
Practice Address - Phone:423-623-2890
Practice Address - Fax:423-623-2924
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4759225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant