Provider Demographics
NPI:1568614394
Name:BURGESS GONZALEZ, MANDIE LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:LYNN
Last Name:BURGESS GONZALEZ
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 1:649 JOHN OHARA ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-1607
Mailing Address - Country:US
Mailing Address - Phone:570-933-0072
Mailing Address - Fax:
Practice Address - Street 1:649 JOHN OHARA ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1607
Practice Address - Country:US
Practice Address - Phone:570-933-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008109225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant