Healthcare Provider Details

I. General information

NPI: 1093679342
Provider Name (Legal Business Name): MADELYN VAVRA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5970 CHURCHVIEW DR
ROCKFORD IL
61107-2574
US

IV. Provider business mailing address

29624 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9267
Mailing address:
  • Phone: 815-971-7000
  • Fax: 815-968-4795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.016938
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9049-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: