Provider Demographics
NPI:1720571276
Name:SMALL, RANDI SU (PTA)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:SU
Last Name:SMALL
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 1:2344 E SIERRA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1716
Mailing Address - Country:US
Mailing Address - Phone:641-777-8248
Mailing Address - Fax:
Practice Address - Street 1:2344 E SIERRA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1716
Practice Address - Country:US
Practice Address - Phone:641-777-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8368A261QP2000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy