Provider Demographics
NPI:1093596702
Name:EBELING, MADISON MAE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MAE
Last Name:EBELING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MERCHANT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5816
Mailing Address - Country:US
Mailing Address - Phone:573-777-8783
Mailing Address - Fax:
Practice Address - Street 1:4200 MERCHANT ST STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5816
Practice Address - Country:US
Practice Address - Phone:573-777-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023039468224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant