Provider Demographics
NPI:1760615389
Name:UNDERWOOD, LIBERTY D (PTA)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:D
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 205
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720-9408
Mailing Address - Country:US
Mailing Address - Phone:816-297-8968
Mailing Address - Fax:
Practice Address - Street 1:402 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MO
Practice Address - Zip Code:64720-9277
Practice Address - Country:US
Practice Address - Phone:816-297-2107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-30
Last Update Date:2009-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016644225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant