Provider Demographics
NPI:1205275708
Name:SHERIDAN-PARKS, MARTY P (PTA)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:P
Last Name:SHERIDAN-PARKS
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 1:8173 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9571
Mailing Address - Country:US
Mailing Address - Phone:904-556-4017
Mailing Address - Fax:
Practice Address - Street 1:8173 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9571
Practice Address - Country:US
Practice Address - Phone:904-556-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502001870OtherPHYSICAL THERAPIST ASSISTANT LICENSURE