Provider Demographics
NPI:1043280837
Name:BURNS, MANDY JO (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:JO
Last Name:BURNS
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:JO
Other - Last Name:HOODJER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT, ATC
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:32 E MAIN ST
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-0474
Mailing Address - Country:US
Mailing Address - Phone:641-753-6636
Mailing Address - Fax:641-753-1005
Practice Address - Street 1:32 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-4903
Practice Address - Country:US
Practice Address - Phone:641-753-6636
Practice Address - Fax:641-753-1005
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03707225100000X
IA004022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0456491Medicaid
IA37162OtherBLUE CROSS BLUE SHIELD
IA0456491Medicaid