Healthcare Provider Details

I. General information

NPI: 1497204689
Provider Name (Legal Business Name): ASHLEY MADAJCZYK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 ARTHUR BLVD
MERRILLVILLE IN
46410-3766
US

IV. Provider business mailing address

7250 ARTHUR BLVD
MERRILLVILLE IN
46410-3766
US

V. Phone/Fax

Practice location:
  • Phone: 219-649-7445
  • Fax: 219-649-7446
Mailing address:
  • Phone: 219-649-7445
  • Fax: 219-649-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32003086A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003874
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: