Healthcare Provider Details

I. General information

NPI: 1114945185
Provider Name (Legal Business Name): TODD A MCLODA PHD, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 HORTON
NORMAL IL
61790-5120
US

IV. Provider business mailing address

1603 SANDERSON CT
NORMAL IL
61761-4267
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-2605
  • Fax:
Mailing address:
  • Phone: 309-268-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: