Provider Demographics
NPI:1598248791
Name:MADSEN, LEIF (PHD, ATC)
Entity Type:Individual
Prefix:DR
First Name:LEIF
Middle Name:
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 E MATTATHA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-9413
Mailing Address - Country:US
Mailing Address - Phone:608-215-3688
Mailing Address - Fax:
Practice Address - Street 1:3044 E MATTATHA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4740
Practice Address - Country:US
Practice Address - Phone:608-215-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002883A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty