Provider Demographics
NPI:1700367059
Name:MCDANIEL, JUDY ELAINE (PT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ELAINE
Last Name:MCDANIEL
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 1:3804 CRESTLINE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2723
Mailing Address - Country:US
Mailing Address - Phone:432-559-3493
Mailing Address - Fax:
Practice Address - Street 1:3000 MOCKINGBIRD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-1608
Practice Address - Country:US
Practice Address - Phone:432-694-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-5143-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1-5143-1OtherPHYSICAL THERAPY LICENSE