Provider Demographics
NPI:1902177587
Name:ADDISON, ALLEN WAYNE (LPTA)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:WAYNE
Last Name:ADDISON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 GEORGIA ST SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-5380
Mailing Address - Country:US
Mailing Address - Phone:704-933-3781
Mailing Address - Fax:
Practice Address - Street 1:1810 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6434
Practice Address - Country:US
Practice Address - Phone:704-933-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA372225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant