Provider Demographics
NPI:1609124916
Name:MADDOX, HEATHER L (PT/DPT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:L
Last Name:MADDOX
Suffix:
Gender:F
Credentials:PT/DPT
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:HOLLABAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT/DPT
Mailing Address - Street 1:913 WEST BUSINESS HWY 60 SELECT PHYSICAL THERAPY
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841
Mailing Address - Country:US
Mailing Address - Phone:573-624-6405
Mailing Address - Fax:573-624-6314
Practice Address - Street 1:913 W BUS HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-2704
Practice Address - Country:US
Practice Address - Phone:573-624-6405
Practice Address - Fax:573-624-6314
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist