Provider Demographics
NPI:1326771411
Name:BAZAN, MADELINE FAYE (OTD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:FAYE
Last Name:BAZAN
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8511
Mailing Address - Country:US
Mailing Address - Phone:515-313-6619
Mailing Address - Fax:
Practice Address - Street 1:9500 UNIVERSITY AVE STE AND1116
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1888
Practice Address - Country:US
Practice Address - Phone:515-987-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA115246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist