Provider Demographics
NPI:1679978316
Name:MAHEADY, BRIANNE LESIA (DPT)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:LESIA
Last Name:MAHEADY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:L
Other - Last Name:WALDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:3465 BOX HILL CORPORATE CENTER DR
Practice Address - Street 2:SUITE G
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1261
Practice Address - Country:US
Practice Address - Phone:410-569-4806
Practice Address - Fax:410-569-5474
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD381317Y5FMedicare PIN