Provider Demographics
NPI:1255047015
Name:BURRELL, MAX (PTA)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:BURRELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 PARK DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-3501
Mailing Address - Country:US
Mailing Address - Phone:407-692-6553
Mailing Address - Fax:
Practice Address - Street 1:1007 PARK DR
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-3501
Practice Address - Country:US
Practice Address - Phone:407-692-6553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA32152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA32152OtherFLORIDA STATE BOARD OF PHYSICAL THERAPY