Provider Demographics
NPI:1386960508
Name:ARCHER, BRENDA LEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:ARCHER
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 1:1498 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-8695
Mailing Address - Country:US
Mailing Address - Phone:570-449-8205
Mailing Address - Fax:
Practice Address - Street 1:1510 HIGHWAY 61 SOUTH
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-8409
Practice Address - Country:US
Practice Address - Phone:570-385-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1000199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant