Provider Demographics
NPI:1629731724
Name:TEAGUE, MADISON SYLVIA
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SYLVIA
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:SYLVIA
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 CAPERIOLE PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-8307
Mailing Address - Country:US
Mailing Address - Phone:631-806-2971
Mailing Address - Fax:
Practice Address - Street 1:2310 CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-0791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007568A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist