Healthcare Provider Details

I. General information

NPI: 1902887664
Provider Name (Legal Business Name): DANIEL WILSON HEADRICK PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 RAYMOND HIRSCH PKWY SUITE #1
WHITE HOUSE TN
37188-4332
US

IV. Provider business mailing address

PO BOX 9
WHITE HOUSE TN
37188-0009
US

V. Phone/Fax

Practice location:
  • Phone: 615-672-2977
  • Fax: 615-672-2979
Mailing address:
  • Phone: 615-672-2977
  • Fax: 615-672-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000003054
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: