Provider Demographics
NPI:1952397002
Name:SANSONE, CHERISSE MARY (PT)
Entity type:Individual
Prefix:MS
First Name:CHERISSE
Middle Name:MARY
Last Name:SANSONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1397
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0035
Mailing Address - Country:US
Mailing Address - Phone:706-782-2585
Mailing Address - Fax:706-782-2012
Practice Address - Street 1:1218 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-3020
Practice Address - Country:US
Practice Address - Phone:706-782-2585
Practice Address - Fax:706-782-2012
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBSWMedicare ID - Type Unspecified
GA00961111AMedicaid