Provider Demographics
NPI:1861670564
Name:WIST, CHERYL (PTA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:WIST
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 1:3001 W GROVE PL
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-6067
Mailing Address - Country:US
Mailing Address - Phone:724-625-4971
Mailing Address - Fax:
Practice Address - Street 1:3001 W GROVE PL
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-6067
Practice Address - Country:US
Practice Address - Phone:724-625-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE007518225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant