Provider Demographics
NPI:1659693265
Name:SPRAGUE, DEANNA RENEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:RENEE
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:DEANNA
Other - Middle Name:RENEE
Other - Last Name:MATHIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:117 ORVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-1309
Mailing Address - Country:US
Mailing Address - Phone:410-686-2270
Mailing Address - Fax:410-686-5447
Practice Address - Street 1:117 ORVILLE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-1309
Practice Address - Country:US
Practice Address - Phone:410-686-2270
Practice Address - Fax:410-686-5447
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2251225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant