Provider Demographics
NPI:1710195573
Name:THACKER, SARA (PTA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:THACKER
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 1:3854 W FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8522
Mailing Address - Country:US
Mailing Address - Phone:317-345-6062
Mailing Address - Fax:
Practice Address - Street 1:3077 E 98TH ST
Practice Address - Street 2:SUITE 265
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2940
Practice Address - Country:US
Practice Address - Phone:317-569-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002816A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant