Basic Information
| Provider Information | |||||||||
| NPI: | 1184132979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORTHINGTON | ||||||||
| FirstName: | MAKENZIE | ||||||||
| MiddleName: | RADCLIFF | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10753 FALLS RD STE 235 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105832666 | ||||||||
| FaxNumber: | 4108473838 | ||||||||
| Practice Location | |||||||||
| Address1: | 4924 CAMPBELL BLVD STE 130A | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212365909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434422810 | ||||||||
| FaxNumber: | 4434422808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2018 | ||||||||
| LastUpdateDate: | 01/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 26797 | 01 | MD | BOARD OF PHYSICAL THERAPY EXAMINERS PHYSICAL THERAPIST LICENSE | OTHER |