Provider Demographics
NPI:1891884995
Name:BURK, SALLY ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ELIZABETH
Last Name:BURK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BURK STATION RD
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-7035
Mailing Address - Country:US
Mailing Address - Phone:601-799-0248
Mailing Address - Fax:
Practice Address - Street 1:200 N MILITARY RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1624
Practice Address - Country:US
Practice Address - Phone:985-641-2996
Practice Address - Fax:985-639-8014
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS1475225100000X
LA00620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00311934Medicare ID - Type UnspecifiedMEDICARE RAILROAD
MS650000312Medicare ID - Type UnspecifiedPROVIDER NUMBER