Provider Demographics
NPI:1699755991
Name:SISSOM, SCOTTIE RAY (BSPT)
Entity type:Individual
Prefix:MR
First Name:SCOTTIE
Middle Name:RAY
Last Name:SISSOM
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:866-800-9147
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:825 NORTH CHANCERY ST
Practice Address - Street 2:
Practice Address - City:MCMINVILLE
Practice Address - State:TN
Practice Address - Zip Code:37111
Practice Address - Country:US
Practice Address - Phone:931-474-1900
Practice Address - Fax:931-474-1904
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare ID - Type Unspecified