Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT8340 | TN |
NPI | 1003041120 |
---|---|
Provider Name | Dana Lee Slack |
First Address | Ooltewah, TN 37363-6511 |
Second Address | Cleveland, TN 37311-3890 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2009 |
Last Update Date | 19/05/2009 |