Healthcare Provider Details

I. General information

NPI: 1376106765
Provider Name (Legal Business Name): MADISON MACKENZIE MILLER OTD, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2019
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6270 N GOVERNMENT WAY
DALTON GARDENS ID
83815-9214
US

IV. Provider business mailing address

6270 N GOVERNMENT WAY
DALTON GARDENS ID
83815-9214
US

V. Phone/Fax

Practice location:
  • Phone: 208-666-0611
  • Fax:
Mailing address:
  • Phone: 208-666-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9471264
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: