Provider Demographics
NPI:1831816263
Name:SOUTHARD, MACIE ROSE (PTA)
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:ROSE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 OLD JACKSBORO HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2700
Mailing Address - Country:US
Mailing Address - Phone:940-386-1004
Mailing Address - Fax:940-386-9944
Practice Address - Street 1:4309 OLD JACKSBORO HWY STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2700
Practice Address - Country:US
Practice Address - Phone:940-386-1004
Practice Address - Fax:940-386-9944
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2173083225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant