Provider Demographics
NPI:1790843431
Name:MADISON, ELIZABETH ANN (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MADISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 BRATLEY DR
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-1143
Mailing Address - Country:US
Mailing Address - Phone:715-373-5621
Mailing Address - Fax:715-373-5244
Practice Address - Street 1:706 BRATLEY DR
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-1143
Practice Address - Country:US
Practice Address - Phone:715-373-5621
Practice Address - Fax:715-373-5244
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3963-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40193600Medicaid