Provider Demographics
NPI:1437916921
Name:BALL, MADISON ALEXIS (COTA/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ALEXIS
Last Name:BALL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 TOWER ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW MILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63362-1136
Mailing Address - Country:US
Mailing Address - Phone:636-290-5047
Mailing Address - Fax:
Practice Address - Street 1:51 TOWER ST
Practice Address - Street 2:
Practice Address - City:MOSCOW MILLS
Practice Address - State:MO
Practice Address - Zip Code:63362-1136
Practice Address - Country:US
Practice Address - Phone:636-290-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024007686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant