Provider Demographics
NPI:1619174547
Name:PRENDERGAST, DEBORA JEAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEBORA
Middle Name:JEAN
Last Name:PRENDERGAST
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 1:7995 KNOX SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-9437
Mailing Address - Country:US
Mailing Address - Phone:330-894-2894
Mailing Address - Fax:
Practice Address - Street 1:400 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8703
Practice Address - Country:US
Practice Address - Phone:330-868-4104
Practice Address - Fax:330-868-7714
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA03600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant