Provider Demographics
NPI:1821766130
Name:MULDOON, MACKENZIE (DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MULDOON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 MOUNT TABOR RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-0427
Mailing Address - Country:US
Mailing Address - Phone:540-641-2998
Mailing Address - Fax:
Practice Address - Street 1:757 UNIVERSITY CITY BLVD
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2705
Practice Address - Country:US
Practice Address - Phone:540-641-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist