Provider Demographics
NPI:1558099796
Name:MADISON, WHITLEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:WHITLEY
Middle Name:
Last Name:MADISON
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 1:2-22 BANTA PL
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3058
Mailing Address - Country:US
Mailing Address - Phone:201-509-8600
Mailing Address - Fax:
Practice Address - Street 1:2-22 BANTA PL
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3058
Practice Address - Country:US
Practice Address - Phone:201-509-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-14
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT5159225100000X
ARPT-5159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist