Healthcare Provider Details

I. General information

NPI: 1033035704
Provider Name (Legal Business Name): MADDISON BANACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 REENA AVE
FORT ATKINSON WI
53538-3145
US

IV. Provider business mailing address

438 W RED PINE CIR
DOUSMAN WI
53118-8823
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-0888
  • Fax:
Mailing address:
  • Phone: 262-431-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17853-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: