Provider Demographics
NPI:1740488675
Name:SLADE, MADILYN SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:MADILYN
Middle Name:SUE
Last Name:SLADE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MADILYN
Other - Middle Name:SUE
Other - Last Name:BOSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1118 N RECKER RD
Mailing Address - Street 2:109
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5504
Mailing Address - Country:US
Mailing Address - Phone:480-833-2778
Mailing Address - Fax:480-833-0232
Practice Address - Street 1:1118 N RECKER RD
Practice Address - Street 2:109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5504
Practice Address - Country:US
Practice Address - Phone:480-833-2778
Practice Address - Fax:480-833-0232
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68-0659242OtherTAX ID
AZ6903OtherLICENSE