Provider Demographics
NPI:1790962850
Name:MADISON, BRENDA ELISA (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ELISA
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 1:6114 PILLORY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5054
Mailing Address - Country:US
Mailing Address - Phone:317-377-6400
Mailing Address - Fax:317-377-1668
Practice Address - Street 1:1251 W 96TH ST
Practice Address - Street 2:#N
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1181
Practice Address - Country:US
Practice Address - Phone:317-377-6400
Practice Address - Fax:317-377-1668
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000862A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant