Provider Demographics
NPI:1780064824
Name:BURTON, DEANDREA (PTA)
Entity type:Individual
Prefix:
First Name:DEANDREA
Middle Name:
Last Name:BURTON
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 1:377 SFC 503
Mailing Address - Street 2:
Mailing Address - City:WIDENER
Mailing Address - State:AR
Mailing Address - Zip Code:72394-9464
Mailing Address - Country:US
Mailing Address - Phone:901-674-0771
Mailing Address - Fax:
Practice Address - Street 1:377 SFC 503
Practice Address - Street 2:
Practice Address - City:WIDENER
Practice Address - State:AR
Practice Address - Zip Code:72394-9464
Practice Address - Country:US
Practice Address - Phone:901-674-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3922225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant