Basic Information
| Provider Information | |||||||||
| NPI: | 1205300324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALTA | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 912 SW CROSS RD | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378037532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156132056 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2304 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659806000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2019 | ||||||||
| LastUpdateDate: | 01/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3907 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 62-1632255 | 01 | TN | EMPLOYEER | OTHER |