Provider Demographics
NPI:1508435272
Name:TADLOCK, ABBIE RAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ABBIE
Middle Name:RAE
Last Name:TADLOCK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MAIN ST UNIT 1710
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64105-2521
Mailing Address - Country:US
Mailing Address - Phone:806-206-7185
Mailing Address - Fax:
Practice Address - Street 1:15319 W 95TH ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-1262
Practice Address - Country:US
Practice Address - Phone:913-495-9905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021021357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist