Provider Demographics
NPI:1093295842
Name:GERSZEWSKI, MADISON NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:GERSZEWSKI
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 1:1019 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-2314
Mailing Address - Country:US
Mailing Address - Phone:701-215-1707
Mailing Address - Fax:
Practice Address - Street 1:5100 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1468
Practice Address - Country:US
Practice Address - Phone:701-215-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
CA20560225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist