=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780219360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELYN ANN PREBOLA OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2020
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6230 STATE RD
-----------------------------------------------------
City | SALINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48176-9832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-944-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10100 HALEY LN APT 207
-----------------------------------------------------
City | WHITMORE LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48189-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-231-6826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5201010694
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------