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General NPI Number Information
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NPI Number | 1790485449
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Entity Type | Individual
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Provider Name | MADISON MAE WITTE COTA/L
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Gender | Female
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Dates
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Enumeration Date | 03/09/2023
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Last Update Date | 03/09/2023
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Provider Practice Location Address
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Address Line | 40 PROFESSIONAL CENTER PKWY
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City | SAN RAFAEL
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State | CA
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Zip | 94903-2703
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Country | US
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Telephone | 415-479-5161
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Fax |
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Provider Business Mailing Address
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Address Line | 316 MARSH ST
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City | TYLER
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State | MN
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Zip | 56178-1136
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Country | US
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Telephone | 507-829-1157
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 488023
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License Number State | OR
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