Basic Information
| Provider Information | |||||||||
| NPI: | 1578751616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LEAKE | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8888 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012594260 | ||||||||
| FaxNumber: | 9012592785 | ||||||||
| Practice Location | |||||||||
| Address1: | 6286 BRIARCREST AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381204023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012591600 | ||||||||
| FaxNumber: | 9012592785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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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 | 5134 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4161223 | 01 | TN | BCBS | OTHER | 7187860 | 05 | MS | MEDICAID | 1512616 | 05 | TN | MEDICAID | 620819926 | 01 | TN | AETNA | OTHER | 620819926 | 01 | MS | BCBS | OTHER | 9101087 | 01 | TN | AETNA | OTHER | 3371161 | 05 | TN | MEDICAID | 110318002 | 05 | AR | MEDICAID | 620819926 | 01 | TN | TRICARE | OTHER | 05430071 | 05 | MS | MEDICAID | 620819926 | 01 | TN | CIGNA | OTHER |