Provider Demographics
NPI:1295457695
Name:MCCARDLE, MONIQUE (PTA)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MCCARDLE
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 1:513 N OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4229
Mailing Address - Country:US
Mailing Address - Phone:503-719-3754
Mailing Address - Fax:
Practice Address - Street 1:1801 W LEA ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3785
Practice Address - Country:US
Practice Address - Phone:575-234-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1982225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant