Provider Demographics
NPI:1639906621
Name:ELDER, MADDIE RAE (MS, ATC)
Entity type:Individual
Prefix:
First Name:MADDIE
Middle Name:RAE
Last Name:ELDER
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:
Other - Last Name:MAURITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1451 OLIVER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-1609
Mailing Address - Country:US
Mailing Address - Phone:817-360-3877
Mailing Address - Fax:
Practice Address - Street 1:1350 EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-1145
Practice Address - Country:US
Practice Address - Phone:817-360-3877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT49452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty