Basic Information
Provider Information | |||||||||
NPI: | 1982823860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'DONNELL | ||||||||
FirstName: | SALLY | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17996 BRUSHY FORK RD SE | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | OH | ||||||||
PostalCode: | 430569435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7407630520 | ||||||||
FaxNumber: | 3308970515 | ||||||||
Practice Location | |||||||||
Address1: | 130 BUENA VISTA ST | ||||||||
Address2: |   | ||||||||
City: | BALTIC | ||||||||
State: | OH | ||||||||
PostalCode: | 438049669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308974311 | ||||||||
FaxNumber: | 3308970515 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1200 | OH | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.