Provider Demographics
NPI:1811658677
Name:BURLESON, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 RIDGEDALE ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-3722
Mailing Address - Country:US
Mailing Address - Phone:979-209-2726
Mailing Address - Fax:
Practice Address - Street 1:1201 RIDGEDALE ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-3722
Practice Address - Country:US
Practice Address - Phone:979-209-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2032100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant