Provider Demographics
NPI:1073289757
Name:LANHAM, MADELINE GRACE (COTA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:GRACE
Last Name:LANHAM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRENTFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-7010
Mailing Address - Country:US
Mailing Address - Phone:502-974-3221
Mailing Address - Fax:
Practice Address - Street 1:15 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1371
Practice Address - Country:US
Practice Address - Phone:502-636-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY459460224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant