Provider Demographics
NPI:1578238846
Name:SANDT, CHARLES DEWAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEWAYNE
Last Name:SANDT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 PALM RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4301
Mailing Address - Country:US
Mailing Address - Phone:321-223-6278
Mailing Address - Fax:
Practice Address - Street 1:1705 JESS PARRISH CT
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2158
Practice Address - Country:US
Practice Address - Phone:321-269-5720
Practice Address - Fax:321-383-9514
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31242225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant