Provider Demographics
NPI:1497122691
Name:SISOUTHAM, SARA CHRISTINE (PTA)
Entity type:Individual
Prefix:MISS
First Name:SARA
Middle Name:CHRISTINE
Last Name:SISOUTHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:CHRISTINE
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3325 PATE WAY
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-8459
Mailing Address - Country:US
Mailing Address - Phone:972-838-2602
Mailing Address - Fax:
Practice Address - Street 1:3325 PATE WAY
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:TX
Practice Address - Zip Code:75409-8459
Practice Address - Country:US
Practice Address - Phone:972-838-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2110040225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant