=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245832153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELINE MAAS DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2020
-----------------------------------------------------
Last Update Date | 11/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1702 S RIVER RD
-----------------------------------------------------
City | JANESVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53546-5648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-373-6322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N353 PRAIRIE VIEW RD
-----------------------------------------------------
City | WALWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53184-5848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 15243-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------