Provider Demographics
NPI:1700197332
Name:WOODWORTH, SANDRA LEE (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:WOODWORTH
Suffix:
Gender:F
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5076
Mailing Address - Country:US
Mailing Address - Phone:219-759-4380
Mailing Address - Fax:219-759-1989
Practice Address - Street 1:3691 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5076
Practice Address - Country:US
Practice Address - Phone:219-759-4380
Practice Address - Fax:219-759-1989
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009054A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic