Provider Demographics
NPI:1851796619
Name:GARTMAN, MADISON (MS, RD, OTR)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GARTMAN
Suffix:
Gender:F
Credentials:MS, RD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:111 COLONY CROSSING WAY STE 250
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6832
Practice Address - Country:US
Practice Address - Phone:601-326-6401
Practice Address - Fax:601-326-6405
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
AK109715225X00000X
MSOT-3913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered