Provider Demographics
NPI:1164039970
Name:MADKINS, BLAIR ELLYSE (COTA/L, BS, AAS)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:ELLYSE
Last Name:MADKINS
Suffix:
Gender:F
Credentials:COTA/L, BS, AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14248 CHAPS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75253-5305
Mailing Address - Country:US
Mailing Address - Phone:936-371-3094
Mailing Address - Fax:
Practice Address - Street 1:14248 CHAPS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75253-5305
Practice Address - Country:US
Practice Address - Phone:936-371-3094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216479OtherTEXAS BOARD OF OCCUPATIONAL THERAPY EXAMINERS