Provider Demographics
NPI:1578751616
Name:MADDOX, STEPHANIE LEAKE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEAKE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8888
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8888
Mailing Address - Country:US
Mailing Address - Phone:901-259-4260
Mailing Address - Fax:901-259-2785
Practice Address - Street 1:6286 BRIARCREST AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4023
Practice Address - Country:US
Practice Address - Phone:901-259-1600
Practice Address - Fax:901-259-2785
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4161223OtherBCBS
MS7187860Medicaid
TN1512616Medicaid
TN620819926OtherAETNA
MS620819926OtherBCBS
TN9101087OtherAETNA
TN3371161Medicaid
AR110318002Medicaid
TN620819926OtherTRICARE
MS05430071Medicaid
TN620819926OtherCIGNA
3650071Medicare PIN
TN3371161Medicaid