Provider Demographics
NPI:1629682679
Name:MCWETHY, MADISON ROSE (ATC, AT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:MCWETHY
Suffix:
Gender:F
Credentials:ATC, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 FONTAINE TRL
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-9722
Mailing Address - Country:US
Mailing Address - Phone:517-648-9664
Mailing Address - Fax:
Practice Address - Street 1:2025 N TOWERVIEW BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-7002
Practice Address - Country:US
Practice Address - Phone:517-648-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer