Provider Demographics
NPI:1376924811
Name:MACTOUGH, JOAN (PT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:MACTOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8240 W. CACTUS RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-878-9696
Mailing Address - Fax:623-776-0668
Practice Address - Street 1:8240 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5231
Practice Address - Country:US
Practice Address - Phone:623-878-9696
Practice Address - Fax:623-776-0668
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ026411Medicaid