=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790659035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISEN GRACE MUSGROVE OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2025
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1447 W MONTROSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-624-8750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14540 TWIN PEAKS RD
-----------------------------------------------------
City | POWAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92064-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 056.016793
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------