Provider Demographics
NPI:1265208268
Name:GILLEN, MADISON (PT, DPT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GILLEN
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 1:7526 MAIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7385
Mailing Address - Country:US
Mailing Address - Phone:774-274-7326
Mailing Address - Fax:
Practice Address - Street 1:9030 OLD ANNAPOLIS RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1990
Practice Address - Country:US
Practice Address - Phone:443-979-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD297162251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports