Provider Demographics
NPI:1972768976
Name:MILES, SANDRA LEE (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MILES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:MENTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4630 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1843
Mailing Address - Country:US
Mailing Address - Phone:614-370-6444
Mailing Address - Fax:
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-957-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-20
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 222Q00000X
OHPT5419225100000X
FL31207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist