Provider Demographics
NPI:1659733517
Name:FORTSON, SANDY LEE (PTA)
Entity Type:Individual
Prefix:MS
First Name:SANDY
Middle Name:LEE
Last Name:FORTSON
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 1:548 WHITE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-8183
Mailing Address - Country:US
Mailing Address - Phone:704-859-5379
Mailing Address - Fax:
Practice Address - Street 1:548 WHITE OAKS DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-8183
Practice Address - Country:US
Practice Address - Phone:704-859-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2946225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant