Healthcare Provider Details

I. General information

NPI: 1194113050
Provider Name (Legal Business Name): MS. JULIE UNDERWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 13TH ST HUNTINGTON WV
HUNTINGTON WV
25701-1653
US

IV. Provider business mailing address

101 13TH ST HUNTINGTON WV
HUNTINGTON WV
25701-1653
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7622
  • Fax:
Mailing address:
  • Phone: 304-525-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001839
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: