Provider Demographics
NPI:1881043537
Name:BURKE, MADISON MACKENZIE (DPT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MACKENZIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 S DE LACEY AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2053
Mailing Address - Country:US
Mailing Address - Phone:626-360-2717
Mailing Address - Fax:626-360-3717
Practice Address - Street 1:188 S DE LACEY AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2053
Practice Address - Country:US
Practice Address - Phone:626-360-2717
Practice Address - Fax:626-360-3717
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210301225100000X
CA292582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist