Provider Demographics
NPI:1316052251
Name:MACDONALD, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MACDONALD
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 1:300 DUCKY LN
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-7426
Mailing Address - Country:US
Mailing Address - Phone:731-377-9581
Mailing Address - Fax:
Practice Address - Street 1:946 E. REED ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851
Practice Address - Country:US
Practice Address - Phone:573-359-3459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006034224OtherOT LICENSE FOR MO
TN3224OtherLICENSE #