Healthcare Provider Details

I. General information

NPI: 1417874900
Provider Name (Legal Business Name): MADDIE LIST OTR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2026
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
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 Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MADELINE LIST
Title or Position: OWNER
Credential: OTR/L
Phone: 845-234-5992