Provider Demographics
NPI:1760536973
Name:MCINNIS, CYNTHIA D (PT)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:D
Last Name:MCINNIS
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 1:227 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4722
Mailing Address - Country:US
Mailing Address - Phone:575-625-2525
Mailing Address - Fax:575-627-5934
Practice Address - Street 1:227 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4722
Practice Address - Country:US
Practice Address - Phone:575-625-2525
Practice Address - Fax:575-627-5934
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72989Medicaid
NM72989Medicaid