Provider Demographics
NPI:1700448685
Name:MCCLAREY, JOANNA ZIDICK (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:ZIDICK
Last Name:MCCLAREY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 N WADE ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-1822
Mailing Address - Country:US
Mailing Address - Phone:573-581-4296
Mailing Address - Fax:
Practice Address - Street 1:639 N WADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-1822
Practice Address - Country:US
Practice Address - Phone:573-581-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020256372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002025637OtherMISSOURI STATE BOARD OF REGISTRATION FOR THE HEALING ARTS: ATHLETIC TRAINER