Provider Demographics
NPI:1811223159
Name:BURKE, STORMY LYN (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:STORMY
Middle Name:LYN
Last Name:BURKE
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 N DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2719
Mailing Address - Country:US
Mailing Address - Phone:937-898-3780
Mailing Address - Fax:937-898-3781
Practice Address - Street 1:7805 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2719
Practice Address - Country:US
Practice Address - Phone:937-898-3780
Practice Address - Fax:937-898-3781
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 01617225200000X
OH33.007992225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant