Provider Demographics
NPI:1922590843
Name:SHORT, SANDRA BURNLEY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:BURNLEY
Last Name:SHORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:LEA
Other - Last Name:BURNLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:5 OTIS CT
Mailing Address - Street 2:
Mailing Address - City:NEW FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:17349-9755
Mailing Address - Country:US
Mailing Address - Phone:757-291-4589
Mailing Address - Fax:
Practice Address - Street 1:5 OTIS CT
Practice Address - Street 2:
Practice Address - City:NEW FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:17349-9755
Practice Address - Country:US
Practice Address - Phone:757-291-4589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4930225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty