Provider Demographics
NPI:1811239098
Name:RECEDE, ROXANNE CARANDANG
Entity Type:Individual
Prefix:MISS
First Name:ROXANNE
Middle Name:CARANDANG
Last Name:RECEDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1637
Mailing Address - Country:US
Mailing Address - Phone:417-553-0651
Mailing Address - Fax:
Practice Address - Street 1:2639 E 5TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1637
Practice Address - Country:US
Practice Address - Phone:417-553-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT- 3606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist