Healthcare Provider Details

I. General information

NPI: 1376214718
Provider Name (Legal Business Name): MADELEINE MCQUALITY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD STE 120
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

1 CHILDRENS PL STE 4E-2
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070.026218
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: