Basic Information
| Provider Information | |||||||||
| NPI: | 1891884995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURK | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 BURK STATION RD | ||||||||
| Address2: | |||||||||
| City: | CARRIERE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394267035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017990248 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N MILITARY RD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704611624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856412996 | ||||||||
| FaxNumber: | 9856398014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MS1475 | MS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 00620 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.