Provider Demographics
NPI:1376164244
Name:SPRINGER, MADELINE ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:SPRINGER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19230 LARKSPUR AVE N
Mailing Address - Street 2:
Mailing Address - City:MARINE ON SAINT CROIX
Mailing Address - State:MN
Mailing Address - Zip Code:55047-9696
Mailing Address - Country:US
Mailing Address - Phone:651-472-6597
Mailing Address - Fax:
Practice Address - Street 1:19230 LARKSPUR AVE N
Practice Address - Street 2:
Practice Address - City:MARINE ON SAINT CROIX
Practice Address - State:MN
Practice Address - Zip Code:55047-9696
Practice Address - Country:US
Practice Address - Phone:651-472-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106241225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106241OtherMINNESOTA BOARD OF OCCUPATIONAL THERAPY