Provider Demographics
NPI:1629133517
Name:MADISON, PATRICIA JEAN (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:JEAN
Last Name:MADISON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2399 ARIEL ST N
Mailing Address - Street 2:SUITE A
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2203
Mailing Address - Country:US
Mailing Address - Phone:651-773-0354
Mailing Address - Fax:651-773-0371
Practice Address - Street 1:2399 ARIEL ST N
Practice Address - Street 2:SUITE A
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2203
Practice Address - Country:US
Practice Address - Phone:651-773-0354
Practice Address - Fax:651-773-0371
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103304225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN78G04MAOtherBLUE CROSS MN NUMBER