Provider Demographics
NPI:1194483024
Name:WOLODKEVICH, MAGGIE ALEXANDRA (ATC)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ALEXANDRA
Last Name:WOLODKEVICH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MIRADA DR N UNIT 423
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-7707
Mailing Address - Country:US
Mailing Address - Phone:614-814-8054
Mailing Address - Fax:
Practice Address - Street 1:6100 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2062
Practice Address - Country:US
Practice Address - Phone:614-366-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0063642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT006364OtherOHIO STATE ATHLETIC TRAINING LICENSE
2000041855OtherBOC NUMBER FOR ATHLETIC TRAINERS