Provider Demographics
NPI:1972281210
Name:BEASLEY, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BEASLEY
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 1:200 MEDICAL PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78738-1796
Mailing Address - Country:US
Mailing Address - Phone:737-237-0016
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PKWY STE 260
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1796
Practice Address - Country:US
Practice Address - Phone:737-237-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1378170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist