=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093512923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON DOMINICA HENDRICKS PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2025
-----------------------------------------------------
Last Update Date | 02/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 980 WOODSTOCK PKWY STE 200
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30188-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-445-9799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 583 SUMMIT PT
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-5860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT017619
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------