Provider Demographics
NPI:1104821172
Name:RADER, SANDRA LOUISE (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOUISE
Last Name:RADER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S BEST AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-1217
Mailing Address - Country:US
Mailing Address - Phone:610-760-1520
Mailing Address - Fax:610-760-1721
Practice Address - Street 1:128 STATE HIGHWAY 94
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825
Practice Address - Country:US
Practice Address - Phone:908-362-6172
Practice Address - Fax:908-362-6406
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015016225100000X
NJ40QA00420600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA394529Medicare ID - Type Unspecified