Provider Demographics
NPI:1053067454
Name:NUGENT, MADISON MAE SCHANTZ (OTR/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MAE SCHANTZ
Last Name:NUGENT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MC DAVIS LOOP UNIT 7303
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-6807
Mailing Address - Country:US
Mailing Address - Phone:567-204-1278
Mailing Address - Fax:
Practice Address - Street 1:301 W 26TH ST
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4713
Practice Address - Country:US
Practice Address - Phone:850-769-5371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20716225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT20716OtherOCCUPATIONAL THERAPY LICENSE