Provider Demographics
NPI:1871544676
Name:BAILEY, CANDACE MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MICHELLE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:CANDACE
Other - Middle Name:MICHELLE
Other - Last Name:HODGIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:160 DESSIE RE DR
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004
Mailing Address - Country:US
Mailing Address - Phone:901-828-5687
Mailing Address - Fax:
Practice Address - Street 1:8253 HWY 51 N
Practice Address - Street 2:STE 102
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053
Practice Address - Country:US
Practice Address - Phone:901-872-6422
Practice Address - Fax:901-872-6497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00446628Medicaid
TN00446628Medicaid