Provider Demographics
NPI:1821530718
Name:LOVERN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LOVERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 N LAMAR BLVD STE A114
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-1049
Mailing Address - Country:US
Mailing Address - Phone:512-646-4673
Mailing Address - Fax:512-729-0320
Practice Address - Street 1:7801 N LAMAR BLVD STE A114
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-1049
Practice Address - Country:US
Practice Address - Phone:512-646-4673
Practice Address - Fax:512-729-0320
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121973225X00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid