Healthcare Provider Details

I. General information

NPI: 1871154658
Provider Name (Legal Business Name): MADELINE LIST OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LACEY RD STE K
FORKED RIVER NJ
08731-2200
US

IV. Provider business mailing address

1208 LAUREL BLVD
LANOKA HARBOR NJ
08734-2904
US

V. Phone/Fax

Practice location:
  • Phone: 845-234-5992
  • Fax:
Mailing address:
  • Phone: 845-234-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR01182300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: