Provider Demographics
NPI:1417515594
Name:SMALL, MADISON M (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:M
Last Name:SMALL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 DEARBORN AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8118
Mailing Address - Country:US
Mailing Address - Phone:406-214-4098
Mailing Address - Fax:406-258-0645
Practice Address - Street 1:945 WYOMING ST UNIT 135
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2057
Practice Address - Country:US
Practice Address - Phone:406-370-1377
Practice Address - Fax:406-258-0645
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-17127225100000X
WYPT-1874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist