Provider Demographics
NPI:1861745044
Name:WISSINK-GHOST, CYNTHIA K (PT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:K
Last Name:WISSINK-GHOST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:K
Other - Last Name:WISSINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 24858
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-4858
Mailing Address - Country:US
Mailing Address - Phone:480-755-1505
Mailing Address - Fax:480-755-1504
Practice Address - Street 1:2054 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7515
Practice Address - Country:US
Practice Address - Phone:480-755-1505
Practice Address - Fax:480-755-1504
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2688225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00024485Medicare PIN
AZZ73329Medicare PIN