Healthcare Provider Details

I. General information

NPI: 1619716347
Provider Name (Legal Business Name): MADISON MILLER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E MISSOURI AVE STE 100
PHOENIX AZ
85014-2719
US

IV. Provider business mailing address

777 E STELLA LN APT 241
PHOENIX AZ
85014-0010
US

V. Phone/Fax

Practice location:
  • Phone: 602-393-0520
  • Fax:
Mailing address:
  • Phone: 765-650-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOTH009609
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: