Provider Demographics
NPI:1790485449
Name:WITTE, MADISON MAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MAE
Last Name:WITTE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-1136
Mailing Address - Country:US
Mailing Address - Phone:507-829-1157
Mailing Address - Fax:
Practice Address - Street 1:40 PROFESSIONAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2703
Practice Address - Country:US
Practice Address - Phone:415-479-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR488023224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant