Provider Demographics
NPI:1578145975
Name:SANDIFER, MADELINE ELISE RIDOUT (LPTA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ELISE RIDOUT
Last Name:SANDIFER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:ELISE
Other - Last Name:RIDOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2226 WOOD IBIS WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1565
Mailing Address - Country:US
Mailing Address - Phone:757-408-0864
Mailing Address - Fax:
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1199
Practice Address - Country:US
Practice Address - Phone:800-392-9187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605752225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant