Provider Demographics
NPI:1053662213
Name:DAVID, SALLY JOANN (PTA)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:JOANN
Last Name:DAVID
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 HIGHWAY EE
Mailing Address - Street 2:
Mailing Address - City:WESTPHALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65085-2016
Mailing Address - Country:US
Mailing Address - Phone:314-724-3350
Mailing Address - Fax:
Practice Address - Street 1:1024 ADAMS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-3408
Practice Address - Country:US
Practice Address - Phone:573-635-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117328225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant