Provider Demographics
NPI:1750982088
Name:GIFFORD, MADELINE DELAY (PTA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:DELAY
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:DELAY
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:303 NEPUTE ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-6628
Mailing Address - Country:US
Mailing Address - Phone:618-263-7873
Mailing Address - Fax:
Practice Address - Street 1:4624 LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1523
Practice Address - Country:US
Practice Address - Phone:314-351-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020036393225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant