Provider Demographics
NPI:1932302593
Name:MADISON, TERRA (PTA)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64938 235TH ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-5013
Mailing Address - Country:US
Mailing Address - Phone:712-629-3305
Mailing Address - Fax:
Practice Address - Street 1:1600 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4858
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00936225200000X
NE618225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant