Provider Demographics
NPI:1902887664
Name:HEADRICK, DANIEL WILSON (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WILSON
Last Name:HEADRICK
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-0009
Mailing Address - Country:US
Mailing Address - Phone:615-672-2977
Mailing Address - Fax:615-672-2979
Practice Address - Street 1:149 RAYMOND HIRSCH PKWY
Practice Address - Street 2:SUITE #1
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-4332
Practice Address - Country:US
Practice Address - Phone:615-672-2977
Practice Address - Fax:615-672-2979
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000003054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3653687Medicaid
TN3653687Medicaid