Provider Demographics
NPI:1528303872
Name:PENNY, SAM VALE (LPTA)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:VALE
Last Name:PENNY
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-3339
Mailing Address - Country:US
Mailing Address - Phone:918-509-0967
Mailing Address - Fax:
Practice Address - Street 1:1601 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4409
Practice Address - Country:US
Practice Address - Phone:580-762-0927
Practice Address - Fax:580-762-0933
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK675225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant