Provider Demographics
NPI:1356378871
Name:TEDFORD, JOAN H (PT)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:H
Last Name:TEDFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-2946
Mailing Address - Country:US
Mailing Address - Phone:662-473-3400
Mailing Address - Fax:662-473-4389
Practice Address - Street 1:100 E LEE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-627-6734
Practice Address - Fax:662-627-6737
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117600Medicaid
MS00117600Medicaid