Provider Demographics
NPI:1609035765
Name:SANDS, MARIE LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:LYNN
Last Name:SANDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:LYNN
Other - Last Name:YAUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3100 WASHINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-658-4622
Mailing Address - Fax:262-658-1503
Practice Address - Street 1:3100 WASHINGTON ROAD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-658-4622
Practice Address - Fax:262-658-1503
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI300019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant