Provider Demographics
NPI:1780206805
Name:SIDES, SUMMER (PT)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:SIDES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 NORTHWEST LOOP
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1701
Mailing Address - Country:US
Mailing Address - Phone:254-965-2040
Mailing Address - Fax:254-965-7394
Practice Address - Street 1:2269 NORTHWEST LOOP
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1701
Practice Address - Country:US
Practice Address - Phone:254-965-2040
Practice Address - Fax:254-965-7394
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1329539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1329539OtherSTATE LICENSE