Provider Demographics
NPI:1770363095
Name:MADRY, PHEOBE (CHC, LMT, LPN)
Entity type:Individual
Prefix:MRS
First Name:PHEOBE
Middle Name:
Last Name:MADRY
Suffix:
Gender:F
Credentials:CHC, LMT, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 DENTON BLVD NW UNIT D12
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1599
Mailing Address - Country:US
Mailing Address - Phone:850-585-7491
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 202
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1990
Practice Address - Country:US
Practice Address - Phone:850-226-8096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA70938225700000X
FLW55658171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist