Provider Demographics
NPI:1578238101
Name:GAYHEART, MADISON NOEL (PTA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NOEL
Last Name:GAYHEART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 E BOGARDUS ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-1705
Mailing Address - Country:US
Mailing Address - Phone:217-722-1885
Mailing Address - Fax:
Practice Address - Street 1:620 WARRINGTON AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5446
Practice Address - Country:US
Practice Address - Phone:217-446-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant