Provider Demographics
NPI:1659030450
Name:BRADDOCK, TAYLOR MACKENZIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MACKENZIE
Last Name:BRADDOCK
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 1:52 COUNTY ROAD 713
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-7308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130A JAMES OTIS SMITH DRIVE
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:MS
Practice Address - Zip Code:38683
Practice Address - Country:US
Practice Address - Phone:662-223-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7204261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy