Healthcare Provider Details

I. General information

NPI: 1740908748
Provider Name (Legal Business Name): MADISON MACKENZIE CAMPBELL OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N ALLEGHANEY AVE
ODESSA TX
79761-4408
US

IV. Provider business mailing address

620 N ALLEGHANEY AVE
ODESSA TX
79761-4408
US

V. Phone/Fax

Practice location:
  • Phone: 432-332-8244
  • Fax: 432-580-7428
Mailing address:
  • Phone: 432-332-8244
  • Fax: 432-580-7428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number122850
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: