Provider Demographics
NPI:1861584658
Name:BADOLIAN, CYNTHIA THERESE (PTA)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:THERESE
Last Name:BADOLIAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6304 COUNTY ROAD 1820
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:MO
Mailing Address - Zip Code:65789-9171
Mailing Address - Country:US
Mailing Address - Phone:417-204-9696
Mailing Address - Fax:
Practice Address - Street 1:1622 PORTER WAGONER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1806
Practice Address - Country:US
Practice Address - Phone:417-204-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029196225700000X
MO2006029256225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant