Provider Demographics
NPI:1942407499
Name:BURNSIDE, CYBIL LEIGH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CYBIL
Middle Name:LEIGH
Last Name:BURNSIDE
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 1:1867 W GORDON RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-6794
Mailing Address - Country:US
Mailing Address - Phone:317-996-3774
Mailing Address - Fax:
Practice Address - Street 1:255 MEADOW DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1415
Practice Address - Country:US
Practice Address - Phone:317-745-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001485A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant