Provider Demographics
NPI:1285998195
Name:BURGESS, MALIA ALYS (PTA)
Entity type:Individual
Prefix:MISS
First Name:MALIA
Middle Name:ALYS
Last Name:BURGESS
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 1:2125 CLEARVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-4209
Mailing Address - Country:US
Mailing Address - Phone:360-201-8573
Mailing Address - Fax:
Practice Address - Street 1:12400 HIGH BLUFF DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3077
Practice Address - Country:US
Practice Address - Phone:866-871-8519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160043572225200000X
COPTA-12149225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant