Provider Demographics
NPI:1871830703
Name:WHEELER, SUE ALEXANDRA (PTA)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ALEXANDRA
Last Name:WHEELER
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 1:468 130TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-7754
Mailing Address - Country:US
Mailing Address - Phone:620-215-4309
Mailing Address - Fax:
Practice Address - Street 1:915 HORTON ST
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701
Practice Address - Country:US
Practice Address - Phone:620-223-5836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03491314000000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility