Provider Demographics
NPI:1952387045
Name:SANDSTROM, CARL ANDREW (MSPT)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ANDREW
Last Name:SANDSTROM
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 MARKET ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-4625
Mailing Address - Country:US
Mailing Address - Phone:814-726-9050
Mailing Address - Fax:814-726-9629
Practice Address - Street 1:2265 MARKET ST
Practice Address - Street 2:SUITE A
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-4625
Practice Address - Country:US
Practice Address - Phone:814-726-9050
Practice Address - Fax:814-726-9629
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007634L225100000X
PADAPT000113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028776920001Medicaid
PA1028776920001Medicaid