Provider Demographics
NPI:1528669827
Name:SISSOM, DENNIS KIRK (LPTA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:KIRK
Last Name:SISSOM
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 1:26 BROZ RD
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:MO
Mailing Address - Zip Code:63333-2700
Mailing Address - Country:US
Mailing Address - Phone:314-420-8954
Mailing Address - Fax:636-720-3388
Practice Address - Street 1:600 BREEZE PARK DR
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-9139
Practice Address - Country:US
Practice Address - Phone:636-229-5996
Practice Address - Fax:636-720-3388
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117159225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant