Provider Demographics
NPI:1902872609
Name:UPPVALL, SANDRA J (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:UPPVALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:J
Other - Last Name:UPPVALL LUCIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 KAY ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1703
Mailing Address - Country:US
Mailing Address - Phone:607-257-2743
Mailing Address - Fax:607-257-5809
Practice Address - Street 1:111 KAY ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-257-2743
Practice Address - Fax:607-257-5809
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012344225100000X
MA3882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0435OtherPTAN