Provider Demographics
NPI:1154947661
Name:TADLIP, MA LOURDES MADERAZO
Entity type:Individual
Prefix:
First Name:MA LOURDES
Middle Name:MADERAZO
Last Name:TADLIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 WADE AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1237
Mailing Address - Country:US
Mailing Address - Phone:919-828-6251
Mailing Address - Fax:
Practice Address - Street 1:616 WADE AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1237
Practice Address - Country:US
Practice Address - Phone:919-828-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC114552251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics