Provider Demographics
NPI:1144094897
Name:PARKS, MADISYN D
Entity type:Individual
Prefix:
First Name:MADISYN
Middle Name:D
Last Name:PARKS
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 1:102 GLEN EDEN DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MO
Mailing Address - Zip Code:65254-9502
Mailing Address - Country:US
Mailing Address - Phone:660-672-9664
Mailing Address - Fax:
Practice Address - Street 1:860 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MO
Practice Address - Zip Code:65254-1277
Practice Address - Country:US
Practice Address - Phone:660-338-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021043996225200000X
MO2023039891224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant