Healthcare Provider Details

I. General information

NPI: 1871544676
Provider Name (Legal Business Name): CANDACE MICHELLE BAILEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: CANDACE MICHELLE HODGIN PTA

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8253 HWY 51 N STE 102
MILLINGTON TN
38053
US

IV. Provider business mailing address

160 DESSIE RE DR
ATOKA TN
38004
US

V. Phone/Fax

Practice location:
  • Phone: 901-872-6422
  • Fax: 901-872-6497
Mailing address:
  • Phone: 901-828-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3914
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: