Provider Demographics
NPI:1124168463
Name:MADDOX, LEONARD THOMAS (PTA)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:THOMAS
Last Name:MADDOX
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 PALM COVE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8006
Mailing Address - Country:US
Mailing Address - Phone:843-324-1456
Mailing Address - Fax:
Practice Address - Street 1:1291 PALM COVE DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-8006
Practice Address - Country:US
Practice Address - Phone:843-324-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1573225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant