Provider Demographics
NPI:1629290903
Name:SANDRA J UPPVALL, PT, LMT
Entity Type:Organization
Organization Name:SANDRA J UPPVALL, PT, LMT
Other - Org Name:NORTHEAST PHYSICAL THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:UPPVALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:607-257-2743
Mailing Address - Street 1:111 KAY ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1703
Mailing Address - Country:US
Mailing Address - Phone:607-257-2743
Mailing Address - Fax:607-257-5809
Practice Address - Street 1:111 KAY ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1703
Practice Address - Country:US
Practice Address - Phone:607-257-2743
Practice Address - Fax:607-257-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012344-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA0435Medicare UPIN