Provider Demographics
NPI:1790556074
Name:WINFREY, MADISON HALEY (PTA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:HALEY
Last Name:WINFREY
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 1:210 E MIAMI BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-3356
Mailing Address - Country:US
Mailing Address - Phone:918-791-5145
Mailing Address - Fax:
Practice Address - Street 1:2810 S JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2524
Practice Address - Country:US
Practice Address - Phone:417-572-0041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3159225200000X
MO2019039797225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant