Provider Demographics
NPI:1871260265
Name:MALONE, MADELINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7628 BLAINE RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-9360
Mailing Address - Country:US
Mailing Address - Phone:610-585-7366
Mailing Address - Fax:
Practice Address - Street 1:209 9TH ST STE 201
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2235
Practice Address - Country:US
Practice Address - Phone:779-696-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.026022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist