Provider Demographics
NPI:1366998395
Name:SUNDERLAND, LINSEY
Entity type:Individual
Prefix:
First Name:LINSEY
Middle Name:
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 8TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1527
Mailing Address - Country:US
Mailing Address - Phone:208-436-9016
Mailing Address - Fax:208-436-4922
Practice Address - Street 1:1224 8TH STREET, SUITE A
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83610
Practice Address - Country:US
Practice Address - Phone:208-436-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-4605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant