Provider Demographics
NPI:1093290983
Name:MAHAFFEY, MICHAELA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:MARIE
Last Name:MAHAFFEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 17TH ST W
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-1205
Mailing Address - Country:US
Mailing Address - Phone:706-564-3558
Mailing Address - Fax:
Practice Address - Street 1:514 17TH ST W
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-1205
Practice Address - Country:US
Practice Address - Phone:706-564-3558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2377225200000X
IA092077225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant