Provider Demographics
NPI:1821505124
Name:VICKERY, SALLY TERESA (PTA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:TERESA
Last Name:VICKERY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:TERESA
Other - Last Name:KUCERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2514 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054-9766
Mailing Address - Country:US
Mailing Address - Phone:712-251-7029
Mailing Address - Fax:
Practice Address - Street 1:2524 GLENN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-2768
Practice Address - Country:US
Practice Address - Phone:712-226-2253
Practice Address - Fax:712-226-2254
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001498225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant