Provider Demographics
NPI:1427068139
Name:MCDANIEL, TIMOTHY WAYNE (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 SHARON RD
Mailing Address - Street 2:SUITE R
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-3640
Mailing Address - Country:US
Mailing Address - Phone:804-769-7504
Mailing Address - Fax:804-769-7524
Practice Address - Street 1:694 SHARON RD
Practice Address - Street 2:SUITE R
Practice Address - City:KING WILLIAM
Practice Address - State:VA
Practice Address - Zip Code:23086-3640
Practice Address - Country:US
Practice Address - Phone:804-769-7504
Practice Address - Fax:804-769-7524
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305201811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010029686Medicaid
VA010029686Medicaid
VA00V382K02Medicare ID - Type Unspecified