Provider Demographics
NPI:1871838573
Name:ONTIBEROS, MISTY (CPTA)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:ONTIBEROS
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801
Mailing Address - Country:US
Mailing Address - Phone:620-227-1371
Mailing Address - Fax:620-227-1208
Practice Address - Street 1:2020 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6411
Practice Address - Country:US
Practice Address - Phone:620-227-1371
Practice Address - Fax:620-227-1208
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant